QD Clinic: Gout, Sepsis… or Both? Save

Hello and welcome to Gout QD Clinics with RheumNow. My name is Dr. Minolani Day and I'm based in London in the UK, and today's case that we'll be discussing is called Gout, Sepsis, or Both.

So I'd like to tell you about a gentleman whom I saw during an on-call shift in rheumatology. He was a 60-year-old man who was admitted to hospital after an upper gastrointestinal bleed. And just before this he had been newly diagnosed with chronic myeloid leukemia. He also had end-stage kidney disease requiring hemodialysis, and early in his admission he had been treated with almost two weeks of broad-spectrum intravenous antibiotics for presumed sepsis of unknown source. So there's plenty of things going on, very very complex.

Just as he was beginning to improve, the medical team became concerned about both of his knees. So they were swollen, particularly on the left-hand side, and an ultrasound showed that there was bilateral effusions with synovitis. So rheumatology was asked whether this was an inflammatory arthritis and whether aspiration or steroid injection might help.

So as we can see, the picture is not really straightforward. When I went to see him, he told me he'd had knee pain on and off for years, but the swelling was new. When I examined him, both of the knees were swollen, but cool, with surprisingly good range of movement. It was unclear from the history if there had been any redness or warmth prior to this. Looking at his blood tests, his inflammatory markers were still quite high, although they were falling, and his white cell count continued to remain high, but of course he'd just been diagnosed with CML, so the usefulness of this was limited.

So, would you assume this was gout? Would you continue treating as possible septic arthritis? Or would you insist on aspirating the joint, which is of course the gold standard in these cases?

Now the difficulty was that both diagnoses were entirely plausible. It could have been a partially treated septic arthritis, or gout, or both. He had several strong risk factors for gout. So I've mentioned that he was dialysis dependent. He had a documented hyperuricemia and had newly diagnosed leukemia with increased cell turnover. So that's important to consider. But he also had every reason to make us worry about infection, specifically septic arthritis. So he'd recently been septic. He'd already received prolonged antibiotics which could partially treat septic arthritis. And he remained systemically unwell.

The obvious next step was joint aspiration. But unfortunately on this occasion, and subsequently to me seeing him, he kept refusing. He'd had a painful aspiration many years ago and was adamant he didn't want another one, despite a long discussion about why it would be so important, which left us with a genuine diagnostic dilemma.

Management wasn't easy either. So normally we have several options for treating a gout flare, as you'll be aware, but in his case almost all of them were problematic. So his end-stage kidney disease meant colchicine wasn't appropriate. His recent gastrointestinal bleed meant that non-steroidal anti-inflammatories and systemic steroids were unattractive options, and without excluding infection, even an intra-articular steroid injection wasn't really something we could confidently offer, in addition to the fact he was refusing the procedure.

So we continued antibiotics as planned by the treating team, encouraged him to reconsider the aspiration, and planned treatment around whatever additional diagnostic information we could obtain.

So what are the teaching points from this case? The first is probably the most important, and that is never let the diagnosis of gout stop you from thinking about septic arthritis. In fact, even if aspiration had shown the presence of monosodium urate crystals, it would of course still be prudent to check the gram stain and cultures. Crystal arthritis and septic arthritis can coexist. In fact, in around one in 20 people with crystal arthritis, septic arthritis is also present. And of course, finding crystals never excludes infection.

Secondly, it's important to remember that risk factors don't always point in one direction. So this gentleman had multiple reasons to develop gout, but equally he had multiple reasons to develop septic arthritis. And that's exactly the sort of person in whom aspiration becomes even more valuable.

Finally, diagnosing gout is often easier than treating it. So patients with advanced kidney disease, recent gastrointestinal bleeding, malignancy, or other multiple comorbidities frequently can't receive our standard therapies. So choosing a safe treatment requires just as much thought as making the diagnosis.

So all in all, aspiration remains crucial in the diagnosis and management of the hot joint, including for gout. The presence of crystals does not — sorry — the presence of crystals does not exclude infection. The final lesson from this case is that diagnosing gout is
really only half the battle. Treating gout in medically complex patients often requires us to rethink our usual approach. This gentleman had dialysis-dependent kidney failure, a recent gastrointestinal bleed, and a new diagnosis of CML. Non-steroidal anti-inflammatories were inappropriate. Colchicine carried a high risk of toxicity in the context of renal failure, and prolonged high-dose steroids were far from ideal in someone where infection remained on the differential and who was about to start treatment for a hematological malignancy.

In these situations, there often isn't a perfect option. The key is to balance efficacy against safety, involve the wider multidisciplinary team, and individualize treatment rather than reaching automatically for what we would consider a standard regimen.

Thank you for listening, and do look out for more from the gout QD clinics on RheumNow. Thank you.