A 90 y.o. woman is transferred from an OSH with a "felon involving the DIP joint"

What do you notice on her exam?

hint: the distal DIP joint appears involved What is wrong? What should you do?

Our patient had a gouty tophus of the finger.

Gout is a form of arthritis, causing great discomfort in joints because of the deposition of needle-like crystals. Pain swelling and warmth can mimic a septic joint. While the WBC count in the joint fluid is often 10,000-20,000 which is less than a septic joint, it can sometimes be difficult to rule out a septic joint and cultures should always be done.

Podagra is gout of the great toe and was well known in the Middle Ages.

Gout was first identified by the Egyptians in 2640 BC.  Hippocrates referred to it as the “unwalkable disease”. A marked increase in gout was noted in England in the 17th through 20th centuries when wines were laced with lead which increases uric acid.  Fructose is also blamed for the increase since it became available at that time and also raises uric acid.  Throughout history many famous individuals have had gout:  Alexander the Great, Charlemagne,  Henry VIII, Thomas Jefferson, and Ben Franklin to name a few.

While the classic presentation of gout is in the great toe, gout can present in many locations.  10% of the time gout presents as polyarticular arthritis.  Gout has been reported in the middle ear, on the pinna, and  in the pannus.  Gout is more common in males at a ratio of 20:1.  There are two mechanisms by which hyperuricemia can develop:  undersecretion (90%) and overproduction(10%).

There are two kinds of crystal induced arthritis: gout and pseudogout. While the most common sites of gout are the instep, ankle, wrist, knee and finger, the most common sites of pseudogout(calcium pyrophosphate crystals) are  large joints like the knee, elbow and ankle.  Calcium pyrophosphate has also been known to cause cervical myelopathy by deposition in the ligamentum flavum. 

gout crystals are needle like and pseudogout are rhomboid

Untreated the attacks resolve spontaneously in less than 2 weeks.  Acute flares can result from increased levels of uric acid caused by the consumption of beer or liquor or consumption of foods with high purine content.  Decreased levels of uric acid can also precipitate gout such as the use of radiocontrast dye.

Colchicine has been used to treat gout since the time of the Greeks but the first xanthine oxidase inhibitor was developed by George Hitchings and Gertrude Elion in 1988. After their Nobel Prize winning discovery, Allopurinol became the most frequently used uric acid lowering drug.

Our patient had an  I+D of her tophus to culture it.  Crystals were seen in the aspirate. Cultures were negative and she was referred back to her primary for gout treatment.

TRIVIA QUESTION

What do beer drinkers, chickens,  crocodiles and orangutans have in common?

For some evolutionary reason they lack an enzyme called uricase which breaks down uric acid making them susceptible to gout.  

Nuki G, Simkin P, A consise history of gout and hyperuricemia and their treatment. Arthritis Research & Therapy 2006 8, S1.

Andriote J, Every Man a  King: Henry VIII’s Worst affliction is on the rise in America.Atlantic june 4, 2012.

Rivard C, Thomas J, Lanaspa M, Johnson R. Rheumatology, vol 52(3), March 2013;421-426.