Tx and Followup:
This patient was continued on her current regimen of colchicine and allopurinol, along with aggressive rehydration and therapeutic joint aspirations of the knees bilaterally. Blood, urine, and fluid cultures were negative for bacteria. She was discharged after 4 days and seen in follow-up by her primary care manager.
She also has an extensive surgical history that includes left nephrectomy/ureterectomy, left breast lumpectomy with nodes, right total hip arthroplasty, right total knee arthroplasty. Her medication list is long and includes Synthroid 112mcg, Demadex 20mg, colchicine 0.6mg, allopurinol (started 1 month ago) 300 mg, Evista 60mg, prednisone 5mg (stopped 2 weeks ago), Coreg 12.5mg, and Metolazone 5mg.
Although gout is sometimes considered a disease of middle-aged men with an alcoholic history, this patient had a number of conditions that predisposed her to monosodium urate crystal deposition disease (gout). She has a long history of chronic renal insufficiency, resulting from left nephrectomy and ureterectomy necessitated by renal cancer. She also has a history of breast cancer and treatment with cyclosporine. Furthermore, the patient was a widow who was malnourished and chronically dehydrated. The gout was undoubtedly present for many years, as the development of tophi usually occurs 5-8 years after the onset of the fist gouty attack. The patient may or may not have sought treatment for the first several attacks, especially if they were intermittent, because she does have a long history of osteoarthritis.