When A Diabetic Foot Ulcer Is Complicated With Tophaceous Gout

Author(s): 
David M. Davidson, DPM

In an interesting case study, this author discusses the diagnostic workup and multidisciplinary efforts to resolve a longstanding combination of a diabetic foot ulcer and tophaceous gout.

A 77-year-old male with multiple comorbidities presented with a chief complaint of a chronic wound on the right great toe. He noted that the wound had been present for “years.” The patient said that he had previously been evaluated by a vascular surgeon but denied receiving treatment by any wound specialist. The only treatment he had used was an OTC topical antibiotic cream. Additionally, the patient reported having an HgA1C below 7%.

   In regard to the patient’s past medical history, he underwent coronary artery bypass surgery six months prior to his initial visit to our wound center. In addition to having coronary artery disease, the patient had diabetes mellitus, renal insufficiency, hyperlipidemia and tophaceous gout. The patient also had arthroscopic knee surgery in the past. He reported no known allergies. The patient’s current medications included glipizide (Glucotrol, Pfizer), metroprolol (Dutoprol, AstraZeneca), docusate (Colace), digoxin, warfarin, bumetanide (Bumex, Hoffmann-La Roche), rosuvastatin calcium (Crestor, Astra Zeneca), sitagliptin (Januvia, Merck) and mupirocin (Bactroban).

   During the physical examination, the patient was alert and oriented. Dorsalis pedis and posterior tibial pulses were normal and equal bilaterally. He had +1 pitting edema bilaterally. The patient had several subcutaneous tophaceous deposits on the sides of both heels and elbows. The wound on the right great toe (see figure 1) was 2.6 cm x 2.7 cm x 0.4 cm. The base of the wound was covered with significant amounts of tophaceous material. There was mild erythema surrounding the wound but no drainage or odor.
The lab findings revealed a white blood cell count of 10.1 and a uric acid level of 10.2. The X-ray showed significant punched out areas of the interphalangeal joint of the right great toe (see figure 2).

Pertinent Treatment Insights

This patient presented with a very deep and complicated wound. His vascular supply was poor with ankle brachial indices of 0.9 and toe/brachial pressures of 0.4. The patient’s tophaceous gout was never properly addressed nor controlled. Prior to performing any local intervention, we referred the patient for vascular consultation and he subsequently underwent endovascular intervention, which improved perfusion to an acceptable level (TPIs of 0.75). After consultation with his primary physician and nephrologist, the patient began taking febuxostat 40 mg (Uloric, Takeda Pharmaceuticals) daily.

   Figure 3 clearly shows the bed of the wound with tophi. We took the patient to the OR and debrided the wound (see figure 4). Due to the depth of the wound, we applied VAC therapy (KCI) soon after surgery and continuously monitored the wound for progress (see figures 5 and 6).

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