Have we Gout your Attention?

Summary: Title: Have we Gout your Attention? Authors: Alexa Leigh Constantakos, DO 1; Gurdeep Singh, DO 1; Heba Aziza, MD; Mohamad Sharbatji, MD 1 1 Internal Medicine Residency, Advent Health Medical Group, Orlando, FL Background: When evaluating a patient with acute oligo-arthritis involving major joints such as the hip, knee, or shoulder, the differential diagnosis remains broad. Especially in patients with sickle cell disease or immunosuppression as they possess a higher risk for devastating conditions such as septic arthritis and avascular necrosis. In such scenarios, prompt diagnosis and management should be pursued simultaneously to avoid irreversible joint damage. Case: A 31-year-old male with a past medical history of sickle cell anemia, HIV (human immunodeficiency virus), and gout presented for evaluation of severe left hip pain. The patient was found to be tachycardic on presentation with leukocytosis. Initial laboratory data was significant for elevated C-reactive protein at 170.40 mg/L (reference range < 5.00 mg/L). Out of concern for septic arthritis and avascular necrosis, magnetic resonance imaging (MRI) of the left hip was performed. The patient began to develop erythema and tenderness of the left hallux two days later. Findings were consistent with podagra; therefore, he was started on colchicine. MRI of the left hip revealed a moderate to large left hip joint effusion of unclear etiology (Figure 1). Synovial fluid analysis revealed 3+ monosodium urate crystals; fluid differential was comprised of 10,000 nucleated cells of which 60% were neutrophils, and culture demonstrated no growth. Synovial fluid Microgen-X was negative for pathogens. The patient continued to receive colchicine with improvement in symptoms of the left hallux and left hip. He was diagnosed with concomitant L hip and L first metatarsal joint gouty arthritis and discharged with allopurinol. Discussion: Gout is a systemic disease that has been recognized in medicine from an early time, with evidence appearing in medical literature dating back to ancient Greece. There have been advances over the decades in understanding the pathology of hyperuricemia, as well as the diagnosis with the invention of polarized light microscopy. However, there remains difficulty in diagnosing gouty arthritis involving atypical joints in vulnerable populations. Polyarticular gout occurs in less than twenty percent of patients presenting with gout for the first time and can present in hospitalized patients with signs of sepsis. Arthrocentesis should be performed as sensitivity is 85 percent and specificity is 100 percent, as well as to determine co-existing disease including septic arthritis. Conclusion: There remains a need for further research in patients with gout that do not meet the classical presentation for better identification and appropriate treatment. This case report aims to highlight the patients who are at risk for missed or delayed diagnosis. References: Raddatz DA, Mahowald ML, Bilka PJ. Acute polyarticular gout. Ann Rheum Dis. 1983 Apr;42(2):117-22. doi: 10.1136/ard.42.2.117. PMID: 6847258; PMCID: PMC1001082. Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yü TF. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum. 1977 Apr;20(3):895-900. doi: 10.1002/art.1780200320. PMID: 856219.