Msk Dermatology · Year 2 · from Msk Dermatology

Case 1: Acute Gouty Arthritis (Podagra)

Patient Presentation

Demographics: 54-year-old man

Chief Complaint: "I woke up at 3 AM with the worst pain I've ever had in my big toe."

History of Present Illness: The patient describes sudden onset of severe pain in his right first metatarsophalangeal (MTP) joint that awakened him from sleep approximately 8 hours ago. The pain reached maximum intensity within hours and is so severe that even the weight of the bedsheet is unbearable. He notes the joint is swollen, red, and hot. He had a large steak dinner with several beers last night while watching a sports game. He has had one similar, less severe episode affecting the same toe about 18 months ago that resolved spontaneously over a week without medical attention.

Past Medical History:

• Hypertension
• Hyperlipidemia
• Obesity
• Chronic kidney disease stage 2 (eGFR 72 mL/min)

Medications:

• Hydrochlorothiazide 25 mg daily
• Lisinopril 20 mg daily
• Atorvastatin 40 mg daily

Social History:

• Sales manager
• Drinks 2-3 beers daily, more on weekends
• Non-smoker

Family History:

• Father had "gout"

Physical Examination

• Vital Signs: BP 148/92 mmHg, HR 88 bpm, Temp 37.9C, BMI 32 kg/m2
• General: In significant discomfort, holding right foot elevated
• Right Foot:
• First MTP joint: markedly swollen, erythematous, warm
• Exquisite tenderness - cannot tolerate light touch
• Overlying skin appears shiny and tense
• Appears cellulitic
• Other joints: No swelling or tenderness
• Skin: No tophi identified

Workup and Results

Laboratory Studies:

Synovial Fluid Analysis (First MTP aspiration):

Imaging:

• Foot X-ray: Soft tissue swelling at first MTP joint, no erosions or tophi

Clinical Image

Clinical photograph demonstrating acute gouty arthritis of the first metatarsophalangeal joint (podagra) with marked erythema, swelling, and shiny, tense skin overlying the joint. Source: Wikimedia Commons, CC BY-SA 3.0.

Diagnosis

Acute Gouty Arthritis (Podagra) - Crystal-Proven

Diagnostic Certainty:

• Monosodium urate crystals identified on polarized microscopy (gold standard)
• Characteristic clinical presentation (rapid onset, severe pain, first MTP involvement)
• Risk factors present (male, obesity, hypertension, CKD, thiazide diuretic, alcohol, dietary triggers)

Treatment Plan

Acute Attack Management:

1. Colchicine (low-dose regimen): 1.2 mg initially, then 0.6 mg one hour later (total 1.8 mg day 1), then 0.6 mg BID until attack resolves

• Chosen over NSAIDs due to CKD

1. Prednisone: 30 mg daily x 5 days as alternative if colchicine insufficient
2. Ice, elevation, rest

Medication Review:

• Discontinue hydrochlorothiazide (contributes to hyperuricemia)
• Switch to losartan for hypertension (has mild uricosuric effect)

Patient Education:

• Dietary counseling: limit red meat, organ meats, shellfish; reduce alcohol especially beer
• Increase water intake
• Weight loss counseling

Urate-Lowering Therapy Discussion:

• Indication: recurrent attacks (this is his second)
• Plan to start allopurinol 2-4 weeks after acute attack resolves
• Will require flare prophylaxis with colchicine when initiating ULT
• Target serum uric acid <6 mg/dL

Follow-up:

• Recheck uric acid 2-4 weeks after attack (when not acutely inflamed)
• Return if symptoms not improving or worsening

Teaching Points

1. Serum uric acid during attacks: May be normal or even low due to uricosuric effect of inflammation; does not exclude gout
2. Crystal identification is definitive: Needle-shaped negatively birefringent (yellow when parallel to compensator) MSU crystals confirm diagnosis
3. Colchicine low-dose regimen: 1.2 mg + 0.6 mg is as effective as high-dose with far less GI toxicity
4. Diuretics and gout: Thiazides and loop diuretics increase uric acid and gout risk
5. Urate-lowering therapy: Don't start during acute attack (can prolong); start after resolution with prophylactic colchicine to prevent mobilization flares

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