QD97 - Gout Goes Chronic Save
QD97 - Gout Goes Chronic by Dr. Cush
Transcription
This is QT clinic, and I'm doctor Jack Cush with RheumNow. QT clinic is brought to you by the ACR meeting. ACR twenty twenty has gone virtual. You need to go to RheumNow. Our case today is gout goes chronic.
Gout certainly can be an acute and even a chronic disorder. What about this case? 66 year old African American female comes in with a history of gout that's going back to about six, seven years. She says the onset of gout was left toe swelling with pain, redness, swelling, swelling so bad that it, you know, it was it was red and hot and couldn't step on it. Classic.
She went to her family doctor, was given, colchicine, got better, had another attack, and then was started on allopurinol. Initially, a hundred milligrams, then later, three hundred. Yet, on three hundred milligrams a day, she has about five attacks in the last year. This is what she says. She says her attacks last seven to ten days, and they're usually only relieved by Medrol Dose Packs or, five day courses of steroids.
But those work really, really well. So it's not clear that her gout is well controlled. Although she says that she hasn't had an attack in the last three months when she comes in to see me, but she's coming in now because she has gout. She's had all these attacks, but she's got one problematic joint, and that is the ankle. So the ankle's been a problem for like two or three years.
Tender, swollen, wears, uses uses crutches, it's always a problem. She's gone to orthopedist, they've really not done much. They haven't done any imaging. It's not sure what orthopedist she went to who's not doing any imaging. But nonetheless, she's doing badly in that joint.
Her current medicines are allopurinol, and she also takes a a PRN nonsteroidals, But her ankle is, again, a real problem. So I'm willing to give her the diagnosis of gout, acute recurrent gout. Not sure what to do with chronic one ankle monarteritis. A little suspicious, and especially in that it's not really swollen. When you, palpate the the foot, the MTPs, the toes, they're all normal.
Midfoot, all normal. The ankle, talocurl, true ankle joint, all normal. No Achilles tendon problems, but she does have peroneal and posterior tibial tendonitis that is really exquisite and worse, she says, when she stands on it. So she's got a periarticular problem, and then when we do testing, her uric acid's normal. Her uric acid is like five something.
Her labs don't show any inflammation. X rays were done previously, didn't show anything. I ordered an MRI, and she's got a tear of the posterior tibial and just edema about both those tendons. So this now becomes an orthopedic problem. But is it really?
Could this be monosodium urate and uric acid deposition, in a peritendinous way? Could this be a gouty problem in addition to a traumatic problem? This is gonna have to be decided by the orthopedist. Of course, it may be better decided if we did dual energy CT scanning to show that she, in fact, does have urate deposits there, and we might do that. I find that it's not easy to order.
It's often not easy to interpret, and it hasn't been quite the gold mine in my experience diagnostically and clinically in management as it seems like it is in all the journal reports that I reviewed on this. So, again, this person has acute gout that's kind of controlled right now. As long as her SUA is under five, I think we're good. She has no nodules or tophi, but and that's where she is. She's right around five right now.
But the question is, she's got this chronic ankle problem. So I think the takeaway lesson on this was, you know, if you, are not, buying the presentation, if the behavior is not quite what you expect out of gout. If it doesn't smell like gout under these parameters, it's probably not going to be gout, and that's what her current biggest problem, the right ankle, is. It's not a gout problem. I don't believe.
I think it's a traumatic issue. I mean, she's overweight, and and that along with whatever led to the the the tendon, lets to is giving her reinjury of that ankle. Again, if it doesn't respond, then maybe we'll consider it deck scanning. This is what I think about when gout goes chronic. Tune in again for our coverage of ACR twenty twenty.
It's coming up soon.
Gout certainly can be an acute and even a chronic disorder. What about this case? 66 year old African American female comes in with a history of gout that's going back to about six, seven years. She says the onset of gout was left toe swelling with pain, redness, swelling, swelling so bad that it, you know, it was it was red and hot and couldn't step on it. Classic.
She went to her family doctor, was given, colchicine, got better, had another attack, and then was started on allopurinol. Initially, a hundred milligrams, then later, three hundred. Yet, on three hundred milligrams a day, she has about five attacks in the last year. This is what she says. She says her attacks last seven to ten days, and they're usually only relieved by Medrol Dose Packs or, five day courses of steroids.
But those work really, really well. So it's not clear that her gout is well controlled. Although she says that she hasn't had an attack in the last three months when she comes in to see me, but she's coming in now because she has gout. She's had all these attacks, but she's got one problematic joint, and that is the ankle. So the ankle's been a problem for like two or three years.
Tender, swollen, wears, uses uses crutches, it's always a problem. She's gone to orthopedist, they've really not done much. They haven't done any imaging. It's not sure what orthopedist she went to who's not doing any imaging. But nonetheless, she's doing badly in that joint.
Her current medicines are allopurinol, and she also takes a a PRN nonsteroidals, But her ankle is, again, a real problem. So I'm willing to give her the diagnosis of gout, acute recurrent gout. Not sure what to do with chronic one ankle monarteritis. A little suspicious, and especially in that it's not really swollen. When you, palpate the the foot, the MTPs, the toes, they're all normal.
Midfoot, all normal. The ankle, talocurl, true ankle joint, all normal. No Achilles tendon problems, but she does have peroneal and posterior tibial tendonitis that is really exquisite and worse, she says, when she stands on it. So she's got a periarticular problem, and then when we do testing, her uric acid's normal. Her uric acid is like five something.
Her labs don't show any inflammation. X rays were done previously, didn't show anything. I ordered an MRI, and she's got a tear of the posterior tibial and just edema about both those tendons. So this now becomes an orthopedic problem. But is it really?
Could this be monosodium urate and uric acid deposition, in a peritendinous way? Could this be a gouty problem in addition to a traumatic problem? This is gonna have to be decided by the orthopedist. Of course, it may be better decided if we did dual energy CT scanning to show that she, in fact, does have urate deposits there, and we might do that. I find that it's not easy to order.
It's often not easy to interpret, and it hasn't been quite the gold mine in my experience diagnostically and clinically in management as it seems like it is in all the journal reports that I reviewed on this. So, again, this person has acute gout that's kind of controlled right now. As long as her SUA is under five, I think we're good. She has no nodules or tophi, but and that's where she is. She's right around five right now.
But the question is, she's got this chronic ankle problem. So I think the takeaway lesson on this was, you know, if you, are not, buying the presentation, if the behavior is not quite what you expect out of gout. If it doesn't smell like gout under these parameters, it's probably not going to be gout, and that's what her current biggest problem, the right ankle, is. It's not a gout problem. I don't believe.
I think it's a traumatic issue. I mean, she's overweight, and and that along with whatever led to the the the tendon, lets to is giving her reinjury of that ankle. Again, if it doesn't respond, then maybe we'll consider it deck scanning. This is what I think about when gout goes chronic. Tune in again for our coverage of ACR twenty twenty.
It's coming up soon.
If you are a health practitioner, you may Login/Register to comment.
Due to the nature of these comment forums, only health practitioners are allowed to comment at this time.