Discussion


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The image depicts uric acid paste. Laboratory assessment revealed negatively birefringent intracellular crystals consistent with gout. The next best step in treatment would be to refer the patient to a rheumatologist.

Gout is a common cause of joint pain; it may also cause tendon and bursal pain that usually affects the lower extremities. It peaks within 24 hours of onset and may occur intermittently over a patient’s lifetime.  Compared with cellulitis, which is the most common cause of pain and redness in the lower extremities, gout is much less likely to be associated with fever or skin breakdown. Although it may last from days to weeks, gout is unlikely to progress after 24 hours.  Pain and redness may be impressive, but warmth is usually not.  Gout also rarely affects premenopausal women.

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Gout can be diagnosed clinically using the Rome, New York, or American College of Rheumatology criteria, each of which is only approximately 70% sensitive and 85% specific. It can also be diagnosed by imaging or laboratory testing.  Plain radiographs are not particularly sensitive early in the course of the disease but may show large erosions with sclerotic, hook-like overhanging margins and/or calcified tophi in areas with recurrent attacks.  Typically, no osteopenia or joint space narrowing occurs until late in the course of the disease.  Dual energy computed tomography is a better choice when imaging is desired.  Although serum uric acid levels provide little insight during a gout attack, intracellular uric acid crystals in joint fluid are diagnostic, which is why arthrocentesis is usually the diagnostic test of choice for gout.

Treatment of gout attacks may involve opiates for acute pain as well as anti-inflammatory medication such as nonsteroidal anti-inflammatory drugs, steroids, or colchicine to shorten the course of the attack (Table).  Alternate medications may be used to prevent future attacks, but they should not be used during an actual attack because they can worsen the attack.

Case Conclusion

The patient was diagnosed with severe gout. Treatment with steroids and colchicine was initiated following consultation with a rheumatologist.

Table. Gout Overview

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Brady Pregerson, MD, is an emergency physician at Cedars-Sinai Medical Center in Los Angeles and at Tri-City Medical Center in Oceanside, California.

Reference

Pregerson DB. Emergency Medicine 1-Minute Consult Pocketbook. EMresource.org. 2017;5.