Painful, swollen, oozing right great toe

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Painful, swollen, oozing right great toe

J Fam Pract. 2016 May;65(5):E5-E8

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References

1. Harris MD, Siegel LB, Alloway JA. Gout and hyperuricemia. Am Fam Physician. 1999;59:925-934.

2. Dalbeth N, Kalluru R, Aati O, et al. Tendon involvement in the feet of patients with gout: a dual-energy CT study. Ann Rheum Dis. 2013;72:1545-1548.

3. Schlesinger N, Schumacher R, Catton M, et al. Colchicine for acute gout. Cochrane Database Syst Rev. 2006;CD006190.

4. Zhu Y, Pandya BJ, Choi HK. Prevalence of gout and hyperuricemia in the US general population: the National Health and Nutrition Examination Survey 2007–2008. Arthritis Rheum. 2011;63:3136-3141.

5. Roddy E, Doherty M. Epidemiology of gout. Arthritis Res Ther. 2010;12:223.

6. Stewart S, Dalbeth N, Vandal AC, et al. The first metatarsophalangeal joint in gout: a systemic review and meta-analysis. BMC Musculoskelet Disord. 2016;17:69.

7. Wallace SL, Robinson H, Masi AT, et al. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum. 1977;20:895-900.

8. Neogi T, Jansen TL, Dalbeth N, et al. 2015 Gout Classification Criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheumatol. 2015;67:2557-2568.

9. Rosenthal AK. Pseudogout: Presentation, natural history, and associated conditions. In: Wortmann RL, Schumacher HR Jr, Becker MA, et al, eds. Crystal-Induced Arthropathies: Gout, Pseudogout, and Apatite-Associated Syndromes. New York: Taylor and Francis Group;2006:99.

10. Horowitz DL, Katzap E, Horowitz S, et al. Approach to septic arthritis. Am Fam Physician. 2011;84:653-660.

11. Barth WF, Segal K. Reactive arthritis (Reiter’s syndrome). Am Fam Physician. 1999;60:499-507.

12. Beaudoin A, Edison L, Introcaso CE, et al; Centers for Disease Control and Prevention (CDC). Acute rheumatic fever and rheumatic heart disease among children—American Samoa, 2011-2012. MMWR Morb Mortal Wkly Rep. 2015;64:555-558.

13. Zhang W, Doherty M, Bardin T, et al; EULAR Standing Committee for International Clinical Studies Including Therapeutics. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006;65:1312-1324.

Diagnosis: Tophaceous gouty arthritis

The x-ray of the right great toe showed erosions of the metatarsophalangeal (MTP) joint (FIGURE 3). Given the patient’s age, underlying diabetes, skin ulceration, and elevation of CRP and ESR, the initial concern was for septic arthritis and osteomyelitis. However, the absence of leukocytosis and hyperglycemia argued against an infectious process.

The elevated uric acid and multiple tophi suggested gout as a more likely cause. Further inquiry during the patient’s hospitalization revealed that he did have additional risk factors for gout, such as a diet comprised primarily of seafood and animal organs.

The diagnosis of tophaceous gouty arthritis was confirmed by aspiration from the tophus, which demonstrated monosodium urate (MSU) crystals on polarized light microscopy. The patient presented with acute gout on the first right toe overlaying chronic tophaceous gout, complicated by renal failure.

Four phases. Gout progresses through 4 phases: asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout (intervals between acute attacks), and chronic tophaceous gout.¹ Chronic tophaceous gout is characterized by tophi—collections of solid urate in connective tissues (from bone to bursa, tendons, ligaments, and entheses).² There are often multiple tophi and they may be calcified. An acute gouty attack is marked by a relatively sudden increase in pain and swelling, and may improve spontaneously over the course of 7 to 10 days.³

Gout is the most common form of inflammatory arthritis, with a prevalence in the United States of 3.9%.⁴The findings of several studies suggest that the prevalence and incidence of gout have risen in recent decades, which may be attributable to a growing aging population, the rise in obesity, increasing numbers of people who have other conditions such as heart disease, kidney disease, and/or diabetes, and the use of diuretics by individuals with cardiovascular disease.⁵

Painful, swollen, oozing right great toe

References

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