Case #2 A fifty year old male presents to the ER complaining of severe pain in h

Question

Case #2 A fifty year old male presents to the ER complaining of severe pain in his left toe. The pain was sudden in onset and he describes the pain as sharp and non-radiating. He is having difficulty bearing weight on his foot. His past medical history is significant for essential hypertension which is well-controlled with an ACE inhibitor. Examination he states that he enjoys a good meal, likes to dine on game meat, and "I have to have my 20 oz steak at least twice a week." is significant for an inflamed first metatarsophalangeal joint. In passing, What is the term used to describe this condition? 5

Explanation / Answer

(Note: a, b, c, d and e respectively refers to the different parts of the question)

a) Gout: It is a condition caused due to the deposition of uric acid crystals in joints and is marked by a sudden onset usually affecting a single joint ( the big toe etc.). This condition is associated with inflammation, redness, swelling etc. The medical term used specifically when the big toe is affected is Podagra.
b) Presence of uric acid crystals in joint fluid extracted from the inflammed area is the common method of diagnosis. In fact in most cases serum uric acid levels are the best means of diagnosis. A value greater than 7 mg per dL indicates hyperuricemia.
c) Uric acid which is the final metabolite of purine metabolism crystallises in the form of monosodium urate. This can precipitate and deposit in joints and other tissues of the body. When these deposits break out due to other conditions like trauma, reduced temperature, surgery etc. they can initiate an inflammatory reaction by the macrophages. The precipitation of uric acid crystals occurs at high serum levels of uric acid, acidosis, dehydration, chemotherapy and most importantly at low temperatures. This explains why the feet is most commonly affected.
d) Diagnosis includes examination of the synovial fluid for the presence of uric acid crystals, blood tests to look into serum monosodium urate levels and also ESR, white blood cell count etc. X rays, ultrasound.
e) The 4 important drugs that is also used to treat acute attacks include: NSAIDs, corticosteroids, Colchicine, and others including Allopurinol.

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