Case Study: Acute Gouty Arthritis

Introduction

Gout is a disease characterized by abnormal metabolism of uric acid resulting in excess uric acid in blood and tissues.  This is caused by either excess uric acid production or problems with uric acid excretion and can lead to gout and kidney stones.  An estimated six million Americans suffer from gout and this number is increasing.  If untreated, recurrent acute gout can lead to joint destruction and renal damage.  If you work in primary care, you will no doubt treat many patients with gout.  It is important that you be able to recognize and treat this painful disease. 

Case Presentation

A 54-year-old male presents to your clinic with severe pain in his left wrist and right great toe.  The affected joints are swollen, erythematous and exquisitely painful.  He denies injury to these areas as well as fever.  The patient is afebrile with a temperature of 98.8, all vital signs are within normal limits.

The patient has a history of hypertension and hyperlipidemia.  He has been steadily gaining weight over the past few years and is now about 50 pounds overweight.  He states that he drinks four to five beers each night.

On exam, you find that the patient’s wrist and first MTP joint are erythematous and very tender to even light touch.  The patient has limited range of motion of these joints related to pain.  Sensation and capillary refill are intact. Lab values show a WBC of 5,400 (Normal 4,300-10,800) and a Uric Acid level of 9.7 (Normal >7.0).

Based on exam and lab results, you diagnose this patient with gout.  Arthrocentisis of the affected joint can be used to confirm your diagnosis.  Differential diagnoses you should rule out in a patient with an erythematous, inflamed joint include but are not limited to cellulitis, bursitis, rheumatoid arthritis, trauma and septic arthritis.

Management and Outcome

NSAIDs and colchicine are the main treatment for an acute gout attack.  The FDA has approved three NSAIDS for treatment of acute gout; indomethacin, naproxen and sulindac.  Colchicine reduces inflammation at the affected area however many patients do not tolerate it well due to gastrointestinal side effects.  Acute gout will resolve in most patients within three to ten days with or without treatment.  Early onset of treatment leads to improved outcomes.

Patients with more than one attack of acute gout a year should be offered preventative therapy with Allopurinol.  Allopurinol is ineffective in acute gout attack but will help prevent future gout attacks by lowering uric acid levels. A diet low in purines can also help prevent future episodes of gout.  Patients should avoid foods such as beer, red meat and seafood.

Discussion

Gout is a painful disease and can significantly affect a patient’s quality of life.  Treatment of acute gout must be initiated promptly.  In patients with recurrent gout, providers must discuss diet and medication to prevent future attacks.

References

Shiel, William C. “Gout and Diet”, http://www.emedicinehealth.com/gout/article_em.htm.

Rothschild, Bruce “Gout and Pseudogout”, http://emedicine.medscape.com/article/329958-overview.