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Polyarthritis in an ill patient
THE CASE
A 72 year old man was admitted as an emergency complaining of a one week history of severe polyarticular joint pain. He had a prior 10 year history of osteoarthritis of his knees. A year earlier he had been seen by the haematologists with a blood film and bone marrow examination suggestive of myelodysplasia. There was a history of a possible gastrointestinal bleed two months before this admission, possibly relating to a non-steroidal anti-inflammatory drug (NSAID) he had been taking for his osteoarthritis; this had subsequently been discontinued. He had mild chronic obstructive pulmonary disease and his medication on admission was: ranitidine 150 mg twice daily; ferrous sulphate 200 mg three times a day; quinine sulphate 300 mg at night; and salbutamol and becotide inhalers. He had been started recently on unknown antibiotics by his general practitioner for a possible lower respiratory tract infection. There was no family history of note. He admitted to drinking 30 units of alcohol per week. There were no known previous episodes of acute synovitis.
Key points
Arthralgia with hyperuricaemia is not synonymous with gout
MSUM crystal identification is essential to confirm the diagnosis of gout
Crystals may be identified from asymptomatic joint aspiration
Sepsis must always be considered in the differential diagnosis of acute gout
Hypouricaemic treatment is life long and the indications and implications of its use must be clearly discussed with the patient
Hypouricaemic treatment should be continued during acute gout
On examination he was apyrexial but dehydrated and in extreme discomfort; even minor movements of his limbs caused severe pain. There was a suspected tophus on the left third toe and the left wrist. Both elbows, both knees and both ankles were hot and erythematous.
Initial investigations demonstrated: haemoglobin 9.6 g/dl; total white cell count 13.3 × 109/l; neutrophil …