by Al Kline DPM¹

Podiatry Internet Journal  1 (1):2  

Abstract 

Two cases of gouty arthritis are presented.  One case presents the joint manifestations and presentation of typical gout in a lesser digital toe joint.  The second case highlights the ulcerative effects of gout in the lesser digits.  A review of simple treatment options are discussed.

Gout is a very common form of joint arthritis.  It is commonly caused by either over-production of uric acid in the blood stream or under-excretion of uric acid through the kidney.  Hyperuricemia is defined as the serum urate concentration more than two standard deviations (SD) above the laboratory values.  The normal (SD) for serum urate concentration is 5.1 +/- 1.0 mg/dL in men and 4.0 +/- 1.0 mg/dL in women.  [1].  Laboratory blood reviews of uric acid levels are not diagnostic of gout.  Patients can have gout, gouty arthritis and tophus formation with normal uric acid levels in the blood stream.  The diagnosis of gout is often a clinical diagnosis.  Laboratory diagnosis is confirmed by joint aspiration and the visualization of bifringent monosodium urate crystals under the microscope.  The causes of gout can include inherited traits, alcohol consumption, excessive intake of red and white meats and some medications such as hypertensive medications (Thiazides).  Foods high in purine include foods such as liver, anchovies, kidneys and sweetbreads.  Other foods known to cause gout include shellfish, scallops, peas, lentils asparagus, mushrooms and beans.   The most common cause of isolated first metatarsophalangeal joint inflammation is due to gout or the acute gouty attack.  There are times when gout can present in an isolated small joint in the toe.  This case presents such a condition.

Case Studies 

A 78 year old female presents with gouty tophi to the lesser digits. She presents with swelling and local gouty tophi with no reported history of acute gouty attacks.  The patient has no allergies and is presently on HCTZ and multivitamins.  She presents with increased tophaceous deposition that is easily seen at the level of the distal interphalangeal joints. There have been times when this condition can get painful.  Surgical arthroplasty can be performed, although there is risk of slow healing and possible secondary infection.  There are other times, when the condition ulcerates, that amputation may be a more viable treatment. 

A 55 year old female presents with distal tophaceous ulceration of the third left digit.  She noticed increase pain and swelling to the joint that has been recurrent in nature over the past year.  On this presentation, she sought medical evaluation due to increased redness and “oozing” and “pus” from under the nail.  Upon closer inspection, it was noted that the debris coming from under the nail was tophi.  This case presents with local ulcerative tophaceous gout.  She was treated with aggressively with NSAIDS and colchicine.  Laboratory data revealed normal serum uric acid levels in both patients.  The second patient was treatment parenterally with antibiotics. 

Treatment of gout is divided into initial (acute) and prolonged (chronic) treatment.  Initial treatment of the acute gouty attackshould include strong NSAIDS, colchicine and oral steroids.   Normal dosage of colchicine is 0.6mg every hour with a maximum dose of 8mg.  Colchicine should be discontinued once the gouty attack subsides, stomach upset occurs or diarrhea occurs.  For patients who cannot tolerate colchicine or have allergies or a history of stomach ulcers taking NSAIDS, a medrol dose pack is an effective alternative of treatment.  If patients can tolerate NSAIDS, colchicine and Indomethacin is a good treatment combination for the acute attack.  Indocin should be used sparingly for risk of interstitial nephritis in high doses.  Cold compresses, elevation and rest should also be instituted early in treatment.  Prolonged or chronic treatment of gout is instituted to normalize hyperuricemia in the blood stream. This is especially true in patients who have recurrent attacks of gout.  This is usually accomplished by medications designed to either block uric acid production or help eliminate uric acid excretion.  Probenecid (Benamid) is useful in helping the kidneys eliminate excess uric acid.  Allopurinol (Zyloprim) is the most commonly prescribed medication to block the production of uric acid. 

Surgical treatments are also an important aspect for treating gout.  Gouty tophus is an accumulation of uric acid crystallization within the joints and capsular linings of the joint.  If a patient is experiencing recurrent gouty attacks associated with a bunion deformity, correction of the bunion with removal of gouty tophus, debridement of the joint capsule and removal of prominent bone has been shown to be an effective treatment to prevent recurrent gout in the first metatarsophalangeal joint.  The same can be said for the small joints.  However, there have been occasions when amputation is necessary in the distal joints due to ulcerative changes and complete destruction of the joint.