History: A 55-year-old man presents to the office with pain and swelling of his 1st metatarsophalangeal joint on his right foot which came on in the middle of the night. The patient states even his bedsheet aggravated the pain. He states he has had multiple similar episodes in the past, including in the joints of his hands. The patient states multiple asymmetric joints have been involved at the same time in the past, but that is less frequent. He has been told he has gout but has refused chronic treatment. He takes ibuprofen for his acute attacks but since they are coming more frequently, he is now amenable to try to prevent or cut down on the attacks, which are occurring monthly. He takes hydrochlorothiazide for hypertension and drinks 2-4 beers per day for many years now and tends to favor sardines for lunch and anchovies on his pizza. He has no history of kidney stones.
Physical Examination: Vitals are normal except for a blood pressure of 140/90. Exam reveal asymmetric deformities of the joints of the hand, and painless, subcutaneous nodules, or tophi on the olecranon bursa, proximal and distal interphalangeal joints, and the helix of his ear.
Labs: Normal creatinine. Uric Acid-not done
Radiology: multiple dense soft tissue nodules over the DIPs with erosive changes of the interphalangeal joints with overhanging edges.
Diagnosis: acute on chronic gout
Pathology: Over production or under excretion of uric acid crystals, which coalesce in joints and cause acute attacks, chronic joint damage, and tophi, which are subcutaneous nodules filled with uric acid crystals. Strongly negative birefringence under polarized light microscopy
Treatment: Short course of NSAIDS for the acute attack, followed by colchicine 0.6 mg po bid, given creatinine is normal. Colchicine can be continued for several months and the patient given a trial off the drug. One month after this acute attack, patient should return for a serum uric acid level, as 1/3 of patients will have a normal serum uric acid level during an acute attack. Allopurinol, a drug that lowers the serum uric acid, should be initiated after confirming the uric acid level to be high and after approximately one month since the last attack, as starting allopurinol soon after an acute attack can precipitate another attack. Serum uric acid should be monitored and dose of allopurinol adjusted until uric acid level falls below 6.5. Some doctors prefer 6.0. Since this patient is complicated and has advanced disease, Rheumatology consult should be considered. He should be advised to drink plenty of water to help prevent nephrolithiasis from urate stones, avoid ingestion of sardines and anchovies, and to discontinue alcohol consumption. In addition, hydrochlorothiazide should be discontinued as it increases contributes to high serum uric acid levels. Another blood pressure agent can be found for this patient. Follow-up one month to continue care and to make sure the patient is complying with treatment.
Image appears Courtesy NIH/National Library of Medicine/Medpix/Case Studies
