An 81-year-old woman presents with acute onset of left thumb pain and swelling. She denies any recent injury or trauma to the thumb. She saw her primary care provider 2 days after the pain began and was placed on oral cephalexin. The patient states that the pain and swelling seem to be getting worse despite 2 days of antibiotic therapy. Examination findings include an extremely painful, red, swollen distal phalanx.
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Gout is an inflammatory condition caused by the deposition of monosodium urate crystals in tissue or joints. The prevalence of gout increases with age, and an acute attack at the distal interphalangeal joint is often the first sign of the disease in elderly patients.
Deposition of gouty tophi is a common cause of infection in the hand, with similar findings of acute swelling, erythema, and pain. The patient in this case presented with gouty tophi, seen as white spots in the tissue of the distal phalanx. The differential diagnosis for this patient included acute infection and felon; however, the presence of tophi confirms the diagnosis of gout.1
The definitive diagnosis of gout is ultimately made by the detection of monosodium urate crystals in the tissue. Serum uric acid level is often elevated, although 80% of people with elevated uric acid level will never have a gouty attack.
Reducing inflammation and pain is the first step in treating an acute gouty attack. Oral steroid taper or indomethacin are commonly used anti-inflammatory treatments. Methylprednisolone at 30 to 50 mg is usually given for the first 3 days and the dose is then slowly tapered over the next 7 to 14 days.2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Kann SE, Jacquemin JB, Stern PJ. Simulators of hand infections. Instr Course Lect. 1997;46:69-82.
- Fitzgerald BT, Setty A, Mudgal CS. Gout affecting the hand and wrist. J Am Acad Orthop Surg. 2007;15(10):625-635.