-2 :: Case - 13045 :: - Polyarticular gout
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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.

Additional Discussion:
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.

Discussion Author: Joel McFarland

Gout, an arthropathy due to monosodium urate crystal deposition, occurs in 0.3% of the population. It occurs 20 times more frequently in men than women. When occurring in women, it demonstrates a post-menopausal predilection.

Primary idiopathic gout is due to any of several inborn errors of metabolism, whereas secondary gout is due to a variety of diseases that cause increased production or decreased excretion of uric acid. Secondary gout usually doesn’t demonstrate radiographic changes. Hyperuricemia is not synonymous with gout, since 2-17% of persons suffer the former, with a minority becoming symptomatic.

Radiographic findings appear in 45% of patients 6-8 years after the initial attack. The urate crystals deposit in poorly vascularized tissues, including cartilage, tendon sheaths, and bursae. Typical features of tophaceous gout include normal mineralization, tophi, joint space preservation, punched-out erosions with sclerotic borders and overhanging cortex, and asymmetrical polyarticular distribution.

Significantly, urate deposition in cartilage produces findings typical of osteoarthritis. Urate crystals are not radiopaque, but calcium may precipitate with the urate, resulting in amorphous increased density in tophi. Tophi are characteristically periarticular and found along the extensor surfaces, though they may be intraarticular or even distant from a joint.

65% of patients experience their first attack in the 1st MTP, and eventually 90% of patients demonstrate involvement at that joint. Asymptomatic periods between attacks last from months to years.

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