Gout gone awry: the importance of proper diagnosis
1. Sophia Tessema, MD, MPH
Neuro-Ophthalmology Fellow, Michigan State University, Hurley Medical
Center.
Mailing Address: 965 Fee Rd. A110, East Lansing, MI 48824, USA.
Email: tessemas@msu.edu
2. Abdullahi E. Mahgoub, MD
Geriatric Fellow, Geriatric Medicine Department, Hurley Medical Center.
Mailing Address: 1 Hurley Plaza, Flint, MI 48503, USA.
Email:
abdullahimahgoub@gmail.com
3. Rasha Nakhleh, MD, AGSF
Assistant Professor of Medicine
Division of General Internal Medicine & Geriatrics
Oregon Health & Science University
Mailing Address: 3181 SW Sam Jackson Park Rd L475, Portland, OR 97239,
USA.
Email: nakhlehr@ohsu.eduCorrespondence:
Rasha Nakhleh, MD, AGSF
Assistant Professor of Medicine
Division of General Internal Medicine & Geriatrics
Oregon Health & Science University
Mailing Address: 3181 SW Sam Jackson Park Rd L475, Portland, OR 97239,
USA.
Email: nakhlehr@ohsu.edu
Key Clinical Message:
Gout is the best known type of arthritis with a prevalence of 1-3% in
the western world.[1,2] Although well understood there is growing
evidence of the misdiagnosis of gout from other forms of arthritis.
These errors lead to delay in accurate diagnosis and in appropriate care
for patients with gout.[2]
Case Description:
A 76 year old Caucasian male presented to the clinic with concerns
regarding gait abnormalities for the last 4 months, pain in the arch of
his feet, and numbness and discomfort in multiple joints. The patient
had noted pain and stiffness in his wrists 17 years ago. He was
subsequently evaluated and diagnosed with osteoarthritis. Since that
time, he managed his pain with meloxicam. Approximately 12 years later,
he noticed the sudden onset of nodules in his joints. The patient had no
prior investigation of possible gout and believed his symptoms were due
to osteoarthritis. Physical examination revealed bilateral large firm
tophi on his hands, elbows, knees and feet with ulceration and chalky
white discharge noted on his index fingers. Radiologic x-ray films noted
diffuse soft tissue tophi, destructive changes involving the distal half
of the intermediate phalanx of the 5th finger in the proximal half of
the distal phalanx and erosive changes of the ulnar styloid. Laboratory
workup revealed a slightly increased uric acid level of 8.6 mg/dL.
Radiologic x-ray films noted diffuse soft tissue tophi. Patient was
started on Allopurinol and later switched to Pegloticase infusion
therapy. Significant improvement of joint stiffness and tophus size was
noticed 6 months after continuation of therapy.
Learning Points:
- Gout may be misdiagnosed as other forms of joint disease, particularly
osteoarthritic changes. It is important to recognize the distinction
between these diseases and to do so early to prevent irreversible
joint destruction.
- The role of medication such as Pegloticase can prove beneficial in
improving patient outcomes without the need for surgery in
significantly progressed cases of gout, such as this patient’s gout.
Informed
Consent
Informed consent has been obtained for the publication of this clinical
image.
Authorship
All the authors made substantial contributions to the preparation of
this manuscript and approved the final version for submission.