Patient Case: Gouty Arthritis
A 55-year-old male presents to the clinic with a sudden onset of severe pain, redness, and swelling in the right big toe. The symptoms started overnight and have progressively worsened, making it difficult for him to walk. He describes the pain as intense, throbbing, and unbearable, with even the slightest touch causing discomfort. He has had two similar episodes in the past year, both resolving within a week without medical treatment.
Medical History & Social Background
The patient has a history of hypertension, which is managed with a thiazide diuretic. He admits to regular alcohol consumption, particularly beer, and a diet rich in red meat and seafood. There is a family history of gout in his older brother. He works as a businessman and has a sedentary lifestyle with minimal physical activity.
Physical Examination
• Swollen, warm, erythematous right first metatarsophalangeal (MTP) joint (big toe).
• Severe tenderness on palpation.
• No other joints are affected.
• No fever or systemic signs of infection.
Laboratory & Imaging Findings
• Serum uric acid: Elevated (8.9 mg/dL).
• Synovial fluid analysis: Needle-shaped monosodium urate crystals with negative birefringence under polarized light microscopy.
• X-ray of the foot: No erosions but mild soft tissue swelling.
Diagnosis
Based on the clinical presentation and diagnostic findings, the patient is diagnosed with acute gouty arthritis affecting the right first MTP joint.
Management Plan
1. Acute Attack Treatment
• NSAIDs (e.g., naproxen or indomethacin) for pain relief and inflammation.
• Colchicine as an alternative if NSAIDs are contraindicated.
• Low-dose corticosteroids if the patient cannot tolerate NSAIDs or colchicine.
2. Long-Term Management & Prevention
• Lifestyle modifications: Reduce alcohol intake, avoid purine-rich foods (red meat, seafood), and increase hydration.
• Weight loss and increased physical activity.
• Switch from thiazide diuretics to an alternative antihypertensive if possible.
• Consider urate-lowering therapy (e.g., allopurinol or febuxostat) if recurrent attacks persist.
3. Follow-Up & Monitoring
• Regular monitoring of serum uric acid levels.
• Patient education on recognizing early signs of an attack and preventive measures.
• Evaluation for potential complications, such as chronic tophaceous gout or joint damage.
Challenges & Considerations
• Patient adherence to dietary and lifestyle changes may be difficult.
• Potential drug interactions with antihypertensive medications.
• Risk of chronic gout and joint deformity if left untreated.
Prognosis
With proper acute treatment and long-term uric acid management, the patient can significantly reduce the frequency and severity of future gout attacks. However, non-compliance with lifestyle changes may lead to recurrence and complications.
A) Septic arthritis
B) Rheumatoid arthritis
C) Gouty arthritis
D) Osteoarthritis
A) Serum uric acid level
B) Synovial fluid analysis
C) X-ray of the affected joint
D) Erythrocyte sedimentation rate (ESR)
A) Allopurinol
B) NSAIDs (e.g., naproxen or indomethacin)
C) Methotrexate
D) Hydroxychloroquine
A) Increasing consumption of red meat and seafood
B) Drinking more alcohol, especially beer
C) Reducing purine-rich foods and maintaining hydration
D) Continuing thiazide diuretics for hypertension management
