QD Clinic: The Highs and Lows of a Woman with Gout Save

Welcome to Gout QD Clinics. I'm Dr. Sheila Reyes from the Philippines and today's case is entitled The Highs and Lows of a Woman with Gout. The patient is a 49-year-old female with chronic kidney disease for about one year who presented with bilateral knee and ankle pain and swelling. She claims to have been previously diagnosed with chronic tophaceous gout by another rheumatologist a year prior to consulting my service and was prescribed Febuxostat.

On seeing her for the first time, I was a little skeptical about her gout diagnosis for some reasons. She's female, relatively young and perimenopausal, and the joint pattern and involvement was not very typical of gout, although not rare. So I had to revisit her medical history.

Upon review, she had a 5-year history of recurrent episodic attacks of mono and oligoarthritis involving the ankles and knees which resolved with intermittent use. A year ago, she was diagnosed with chronic kidney disease and was referred to a rheumatologist for the first time because of elevated uric acid and acute monoarthritis of the left knee, resulting in arthrocentesis with intraarticular steroid injection, and eventually received the diagnosis of gout and was started on urate-lowering therapy.

According to her, the diagnosis was made after other workups for arthritis came out negative, but she was unable to show proof of her results upon consulting with me. However, on further review of her history, I found that she was noncompliant with the prescribed Febuxostat and would just self-medicate with colchicine and oral prednisone during attacks of arthritis, usually about three to four times a month.

Pertinent PE findings: I saw that she had moon facies and central obesity. She also had beginning atrophy of both her quadriceps muscles. Both her knees and ankles were swollen and there were multiple subcutaneous tophi on both feet. Her laboratory results show an eGFR of 25, which was consistent with CKD, uric acid level at 6.59 mg per deciliter. CBC showed mild leukocytosis. I proceeded with doing additional workups for the inflammatory arthritis such as rheumatoid factor, anti-CCP, and an ANA, but all came out negative.

Due to the polyarticular nature of the attack, I gave her intravenous hydrocortisone and performed arthrocentesis of both knees. Synovial fluid analysis was consistent with inflammatory arthritis and polarizing microscopy was negative for crystals.

Now if you were the physician handling this case, what would you do? Would you continue treating for gout? We consider the diagnosis of gout and perform additional tests similar to what I did.

I had to re-educate this patient on gout and emphasize the importance of taking maintenance urate-lowering therapy and follow-up. I gradually resumed Febuxostat when the attack subsided and shifted to oral prednisone with gradual taper. I also referred her to the endocrinology service for evaluation and management of a possible concomitant Cushing's syndrome.

Now for me this is still a case of chronic tophaceous gout, but in a female, the history of elevated uric acid, the episodic pattern of the joint pains, including the presence of subcutaneous tophi, helped me in considering the diagnosis of chronic tophaceous gout, but with some kinks including complications that arise with this disease. Her chronic kidney disease may have been due to gouty nephropathy and chronic use, and the presence of Cushing's features suggests that she may have been on chronic steroid use, probably at the time when her nephrologist may have advised her to stop using NSAIDs.

My key takeaways from this case. Number one, history and physical exam is always critical. If the need arises, always revisit the diagnosis, especially when things don't add up. Also consider concomitant diagnoses. Uric acid levels in females rise after menopause, but this doesn't mean that gout will not affect younger women. Other factors may have contributed to this patient's early gout.

Number three, patient education is vital, especially in gout. Apart from understanding the disease, they should also understand the treatment rationale. Why you're giving Febuxostat as maintenance, why colchicine may be of importance as well, and why chronic NSAID use and an as-needed basis of prednisone may not be the best medication for acute gout, or should not be taken long-term especially if not prescribed by the physician, including potential complications if the condition is not managed properly. I believe that patients with gout should really be given an active role in the management of their condition.

And lastly, particularly when chronic tophaceous gout is present, the rheumatologist may play a central role in multidisciplinary management. This is Sheila Reyes from the Philippines and I hope you've learned something from the case I shared.