QD Clinic: When There's Doubt in Gout Save
Dr. Eric Dein discusses how imaging was used in correctly diagnosing a mid-foot symptom in gout.
Transcription
Hello. Welcome to another QD clinic for gout month, brought to you by RheumNow. And I'm going to talk to you about when there's doubt in gout.
This is a patient, a 63-year-old patient with longstanding diabetes on insulin for about the past 15 years. He has been under really good control of his diabetes. His A1Cs have been right about six, and he hasn't had significant complications related to his diabetes. He presented to an orthopedic physician with severe midfoot pain and was diagnosed with Charcot arthropathy. Charcot foot is a diabetic neuroarthropathy. It's progressive, it's destructive. It's usually related to the neuropathy that's present in diabetes where you lose sensation, leading to a kind of repetitive unrecognized trauma that causes inflammation, usually bone loss, eventually fractures, dislocations, subluxations, and significant deformity. Usually associated with diabetes, also attributable sometimes to things like alcohol or other forms of neuropathy. It's usually warm, swollen, erythematous. It's usually not painful despite the extensive damage that's there.
He sees the orthopedic doctor. He's got midfoot destruction. He has a classic rocker bottom of the foot, leading to this diagnosis. It is, however, moderately painful. It's not severely painful the way we often think about for gout, but it's also not painless. He's treated for the Charcot foot with immobilization, in a boot, with a plan for surgical reconstruction.
But he sees his endocrinologist and says, "I haven't really had significant issues with neuropathy. My diabetes has been under really good control. Granted, it has been a long-standing disease. Is this really Charcot?" And so he gets some labs done. His uric acid comes out at 10. And so he comes to see me with the question of is this really Charcot, or could this be gouty? And there's not necessarily one swollen joint or anything to aspirate. And so it's a little hard to say could this be gouty erosive destruction from it. Again, not kind of that traditional pain — again, maybe there's neuropathy that's also numbing that as well.
So we go ahead and we do a DECT scan, the dual-energy CT scan, which highlighted that there was quite a bit of monosodium urate crystals, the gouty crystals, present within his body, which is not a surprise when his uric acid is 10. But in particular, it highlighted that specifically on the midfoot there were extensive deposits that were there. And so that really helped us indicate that this seems to be a gouty problem that we think is driving it.
So when you're not sure in gout, teaching point number one is to think about using the dual-energy CT scan. For him, it helped make the presumptive diagnosis, and that helped us get him started on urate-lowering therapy. We got him to goal. His uric acid is now very well controlled. He's had stabilization of his disease. He's had a surgical reconstruction of his foot, and there's been no signs of any progression of the disease, either from the Charcot neuroarthropathy or from gout.
Number two is seeing the Charcot arthropathy, which is something that we don't necessarily always see in rheumatology, but having it under the differential that gout can sometimes mimic this. So an interesting case for me that I learned a lot from, and a satisfying case when you make the diagnosis, you see those green deposits on that DECT scan, and you intervene with a treat-to-target approach.
I hope you appreciate this case. Check in with RheumNow for a lot more QD clinics and other material for gout month.
This is a patient, a 63-year-old patient with longstanding diabetes on insulin for about the past 15 years. He has been under really good control of his diabetes. His A1Cs have been right about six, and he hasn't had significant complications related to his diabetes. He presented to an orthopedic physician with severe midfoot pain and was diagnosed with Charcot arthropathy. Charcot foot is a diabetic neuroarthropathy. It's progressive, it's destructive. It's usually related to the neuropathy that's present in diabetes where you lose sensation, leading to a kind of repetitive unrecognized trauma that causes inflammation, usually bone loss, eventually fractures, dislocations, subluxations, and significant deformity. Usually associated with diabetes, also attributable sometimes to things like alcohol or other forms of neuropathy. It's usually warm, swollen, erythematous. It's usually not painful despite the extensive damage that's there.
He sees the orthopedic doctor. He's got midfoot destruction. He has a classic rocker bottom of the foot, leading to this diagnosis. It is, however, moderately painful. It's not severely painful the way we often think about for gout, but it's also not painless. He's treated for the Charcot foot with immobilization, in a boot, with a plan for surgical reconstruction.
But he sees his endocrinologist and says, "I haven't really had significant issues with neuropathy. My diabetes has been under really good control. Granted, it has been a long-standing disease. Is this really Charcot?" And so he gets some labs done. His uric acid comes out at 10. And so he comes to see me with the question of is this really Charcot, or could this be gouty? And there's not necessarily one swollen joint or anything to aspirate. And so it's a little hard to say could this be gouty erosive destruction from it. Again, not kind of that traditional pain — again, maybe there's neuropathy that's also numbing that as well.
So we go ahead and we do a DECT scan, the dual-energy CT scan, which highlighted that there was quite a bit of monosodium urate crystals, the gouty crystals, present within his body, which is not a surprise when his uric acid is 10. But in particular, it highlighted that specifically on the midfoot there were extensive deposits that were there. And so that really helped us indicate that this seems to be a gouty problem that we think is driving it.
So when you're not sure in gout, teaching point number one is to think about using the dual-energy CT scan. For him, it helped make the presumptive diagnosis, and that helped us get him started on urate-lowering therapy. We got him to goal. His uric acid is now very well controlled. He's had stabilization of his disease. He's had a surgical reconstruction of his foot, and there's been no signs of any progression of the disease, either from the Charcot neuroarthropathy or from gout.
Number two is seeing the Charcot arthropathy, which is something that we don't necessarily always see in rheumatology, but having it under the differential that gout can sometimes mimic this. So an interesting case for me that I learned a lot from, and a satisfying case when you make the diagnosis, you see those green deposits on that DECT scan, and you intervene with a treat-to-target approach.
I hope you appreciate this case. Check in with RheumNow for a lot more QD clinics and other material for gout month.
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