For 2 days, a 60-year-old man with a history of gout had excruciating pain in the left big toe. During 2 previous episodes, colchicine had relieved his symptoms. On this occasion, colchicine failed to provide relief. The patient's first metatarsophalangeal joint of the left foot was erythematous, hot, and tender. He could not bear weight on the foot. Other physical examination findings were normal.
Alexander K. C. Leung, MD, and Justine H. S. Fong, MD, of Calgary, Alberta, diagnosed gouty arthritis. This abnormality of uric acid metabolism results in hyperuricemia and urate crystal deposition. The patient's serum uric acid level was 628 µmol/L, which confirmed the diagnosis.
Idiopathic hyperuricemia is usually caused by a polygenetically determined reduced renal urate excretion. Persons with gout excrete about 40% less uric acid than those without gout. The condition is often associated with obesity, impaired glucose tolerance, hypertriglyceridemia, and hypertension; however, this patient had none of these conditions.
Gout typically presents as an acute monarthritis. The first metatarsophalangeal joints are most commonly involved, but the tarsal joints, ankles, and knees can also be affected. The affected joints rapidly become inflamed and painful, and the clinical picture resembles cellulitis. Untreated gout may lead to tophi, nephropathy, and uric acid nephrolithiasis.
Acute gout can be treated with oral colchicine or indomethacin and other NSAIDs. Intravenous colchicine should be avoided, because it is associated with a high incidence of serious adverse effects. This patient was treated with indomethacin, 50 mg tid, and his symptoms subsided within 3 days. He was advised that gouty arthritis can be triggered by trauma, heavy alcohol consumption, and excessive intake of red meat.