Recognizing And Treating Lower Extremity Gout

Nicholas Romansky, DPM, FACFAS

Emphasizing The Importance Of A Rheumatologist Consult

The podiatrist’s role in healthcare today is now more critical than ever with the increasing emphasis on comprehensive, collaborative and correlated care among other healthcare professionals. One should consider referral to a rheumatologist or to the primary care physician as part of the treatment course.

   Statistics regarding referral to a rheumatologist and the rheumatologist’s treatment course parallels my experience when referring to a rheumatologist. Patients evaluated by a rheumatologist are: 21.9 percent more likely to have gout diagnosed by synovial fluid analysis; 25.7 percent more likely to have had a culture and sensitivity in the workup; and 18.3 percent more likely to have documented serum urate levels.22 Patients with acute gout who were treated by a rheumatologist were 30.3 percent less likely to need NSAIDs and higher doses of colchicine. Interarticular cortisone injections were 32.4 percent more likely to occur when a rheumatologist treated patients.

   Rheumatologists recommended prophylaxis with allopurinol in 31.1 percent more patients.22 Similar to my personal treatment course, once one obtains target serum urate concentration level of 6.0 mg/dL, one can titrate allopurinol down to lower doses.

Case Study: When A 75-Year-Old Patient Presents With Progressive Swelling In The Legs And Feet Over Six Days

A 75-year-old retired Air Force colonel presents to the office on an emergency basis. I have known him for 13 years. He has a history of midsubstance plantar fasciitis treated by custom orthotics and painful radiculopathy of vertebrae L-4 and L-5 with difficulty walking.

   He recently returned from the Caribbean with progressive swelling of both legs and feet in the last six days. Twenty-four hours after returning home from the Caribbean, he presented to a local hospital emergency room for the progressive swelling of both legs and feet but was discharged. He received no diagnosis except for possible prostatitis. The patient had an extensive workup and doctors told him to take an additional diuretic, hydrochlorothiazide. He did have a urologic consult, which resulted in a catheter implantation and got instructions to follow up with a urologist.

   Six days later, he called the office and came in during our normal evening hours. He presented with a painful ingrown toenail in the left hallux. The patient also had increased difficulty walking (which led him to use a cane), shortness of breath, difficulty urinating, more redness to his feet and ankles, painful fingertips with dischargeof tophi, and painful Achilles tendons with a lack of propulsion. He had no recent history of injury on his trip to the Caribbean.

   The patient regularly sees a number of professionals including a vascular surgeon, an internal medicine physician, a cardiologist and an orthopedist both locally and in the city nearby.

   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.

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