Red Toe
Answer: C
Gout is the most common inflammatory arthritis in men. Primary gout is caused by either overproduction or undersecretion of uric acid. Secondary gout may be caused by renal failure, medications that cause hyperuricemia, and some genetic enzymatic defects.
Most commonly, gout affects the metatarsophalangeal joint of the great toe (podagra); this is monoarticular gout. Polyarticular gout occurs in up to 20% of attacks. Intercritical gout is the term used for signs or symptoms between acute flares.
The differential diagnosis of an acutely inflamed joint is broad, but the main considerations are septic arthritis, gout, rheumatoid arthritis, and calcium pyrophosphate disease (pseudogout). Definitive diagnosis of gout requires demonstration of monosodium urate crystals in synovial fluid or tophi and low white blood cell count and negative gram stain.
Gout is the most common inflammatory arthritis in men. Primary gout is caused by either overproduction or undersecretion of uric acid. Secondary gout may be caused by renal failure, medications that cause hyperuricemia, and some genetic enzymatic defects.
Most commonly, gout affects the metatarsophalangeal joint of the great toe (podagra); this is monoarticular gout. Polyarticular gout occurs in up to 20% of attacks. Intercritical gout is the term used for signs or symptoms between acute flares.
The differential diagnosis of an acutely inflamed joint is broad, but the main considerations are septic arthritis, gout, rheumatoid arthritis, and calcium pyrophosphate disease (pseudogout). Definitive diagnosis of gout requires demonstration of monosodium urate crystals in synovial fluid or tophi and low white blood cell count and negative gram stain.
Although a low-grade fever may accompany a gouty flare, septic arthritis must be ruled out. Some clinical features are helpful in making the diagnosis:
The presence of podagra (C) makes a gouty flare much more likely (LR+ 32); absence of podagra puts the diagnosis into question (LR- 0.04).
After a septic joint is ruled out, treatment can focus on rapid control of the acute inflammatory response. NSAIDs such as indomethacin are safe and effective; they ideally are given with a proton-pump inhibitor and with care in renal insufficiency. Although aspirin is an NSAID, this particular medication reduces uric acid secretion and should be avoided (D); this can be a problem for patients on daily aspirin regimens for circulatory disease.
Allopurinol is a xanthine oxidase inhibitor that promotes secretion of uric acid. Although it is an effective chronic therapy, it should not be used in the acute flare, as any fluctuation in uric acid level can precipitate an episode (A).
Colchicine (extracted from the autumn crocus) is a traditional, but high-risk drug to treat gout. It is essentially a chemotherapeutic agent which inhibits microtubule production – in effect poisoning mitosis. Mild toxicities include gastrointestinal upset (vomiting and diarrhea). However, multisystem organ failure, muscular weakness, respiratory failure, shock, and death are associated with its use. From the ED perspective, colchicine may be considered a medication that may be given as an inpatient by an expert under close supervision. The “old days” of giving outpatients (with whom we have virtually no follow-up) a large amount of cochicine and instructions to “take until you feel better or have diarrhea” should be long gone (B).
A short course of oral steroids, continuing hydration, and avoiding purine-rich foods (meat, some seafood, beer/wine, legumes, etc) are indicated.
The presence of podagra (C) makes a gouty flare much more likely (LR+ 32); absence of podagra puts the diagnosis into question (LR- 0.04).
After a septic joint is ruled out, treatment can focus on rapid control of the acute inflammatory response. NSAIDs such as indomethacin are safe and effective; they ideally are given with a proton-pump inhibitor and with care in renal insufficiency. Although aspirin is an NSAID, this particular medication reduces uric acid secretion and should be avoided (D); this can be a problem for patients on daily aspirin regimens for circulatory disease.
Allopurinol is a xanthine oxidase inhibitor that promotes secretion of uric acid. Although it is an effective chronic therapy, it should not be used in the acute flare, as any fluctuation in uric acid level can precipitate an episode (A).
Colchicine (extracted from the autumn crocus) is a traditional, but high-risk drug to treat gout. It is essentially a chemotherapeutic agent which inhibits microtubule production – in effect poisoning mitosis. Mild toxicities include gastrointestinal upset (vomiting and diarrhea). However, multisystem organ failure, muscular weakness, respiratory failure, shock, and death are associated with its use. From the ED perspective, colchicine may be considered a medication that may be given as an inpatient by an expert under close supervision. The “old days” of giving outpatients (with whom we have virtually no follow-up) a large amount of cochicine and instructions to “take until you feel better or have diarrhea” should be long gone (B).
A short course of oral steroids, continuing hydration, and avoiding purine-rich foods (meat, some seafood, beer/wine, legumes, etc) are indicated.
