Recognizing And Treating Lower Extremity Gout

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Author(s): 
Nicholas Romansky, DPM, FACFAS

   His past medical history includes: atrial fibrillation and ventricular tachycardia, L-5 spine radiculopathy with moderate stenosis at vertebrae L4-5; a positive electromyography of mild motor sensory polyneuropathy; elevated cholesterol; elevated blood pressure; gastroesophageal reflux disease; glaucoma; and multiple joint degenerative joint disease.

   The patient is allergic to warfarin (Coumadin, Bristol-Myers Squibb) and has a history of purple toe syndrome from warfarin. His medications include simvastatin (Zocor), generic omeprazole, tamsulosin (Flomax, Boehringer-Ingelheim), alprazolam (Xanax), candesartan (Atacand), hydrochlorothiazide, metoprolol (Lopressor), Tylenol prn, aspirin 325 mg, bimatoprost (Lumigan, Allergan) timolol and Azopt eye drops.

   In regard to the examination, the patient presented with local redness, tenderness and hypertrophy to the left great toe border. He had increased heat and redness of the right first MPJ, ankles and across both midfoot regions. Edema was +3 of the calf and feet, and there was palpable tenderness to both midfoot regions/ankles.

   I contacted the ER physician and asked the doctor why the patient was discharged at the time of his visit six days prior. The ER doctor said there was no reason for him to be admitted. After much discussion with the ER doctor, he stated that there was no reason even that night to admit the patient with his progressive symptoms. Lab testing results obtained from the ER visit six days prior showed a urinalysis with 30 to 50 white blood cells in the urine, negative glucose/ketones and +1 occult blood. Other lab testing results showed a red blood cell count of 7.3, a white blood cell count of 4.10, potassium 4.1 mmol/L, sodium 138 mmol/L, sugar 128 mg/dL, and a uric acid level of 8.2 mg/dL with no HgA1c completed.

   The EKG showed ventricular tachycardia. X-rays upon examination show significant midfoot degenerative joint disease and soft tissue swelling. His dorsalis pedis pulse was 1+/4 and his posterior tibial pulse was 0/4 B/L.

   Working diagnoses include hyperglycemia, hyperuricemia, possible prostatitis, ventricular tachycardia, acute kidney failure and other organ shut down, and L-5 spine stenosis with radiculopathy.

   During this office visit, I contacted his internal medicine physician and he agreed with me to send him to the nearest ER. We were both concerned about the progressive symptoms. I again contacted the ER doctor and after much pressure, he decided to reconsider the patient coming back to the ER for possible hospitalization with working diagnosis discussed.

   The patient was admitted to the local hospital through the ER and a hospitalist, urologist, vascular surgeon and rheumatologist saw him.

   The final diagnoses include acute prostatitis, acute gout, kidney failure and ventricular tachycardia. Treatment included medical management for hyperuricemia secondary to prostatitis. Once the patient was stable, the patient underwent successful prostate surgery. Within 10 days, the patient was medically stable with significant improvement in swelling with both local and systemic symptoms essentially resolved. All lab testing results returned to near normal values.

   This case demonstrates the important role of the podiatrist for the comprehensive care, collaboration and correlation with other professionals of the healthcare team for the treatment of local and systemic medical issues. This case has become an excellent practice builder. This single case alone has created multiple new patient referrals for both conservative care and surgical intervention.

In Conclusion

Gout is a relatively common inflammatory arthritis that occurs in all age groups. It can be a particularly debilitating disease, causing limitation of activity and lowering the quality of life. It is now associated with the comorbidity of other systemic diseases.

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