The Case of Monoarticular Pain

Our 67 year old woman with an extensive medical history including morbid obesity, coronary artery disease s/p MI, uncontrolled Type II DM (recent A1c 10.2%) with associated neuropathy and retinopathy, CRI, OA, DJD s/p left total knee replacement ’01 is presenting with sudden onset of left ankle pain over the course of the day.  She describes it as sharp and throbbing with associated swelling specifically over her lateral malleolus, worsening over the course of the day to the point of having difficulty bearing weight.

Residents began to establish their working diagnoses by thinking of how to approach monoarthritis.  Of note, a resource that was referenced was the American College of Rheumatology Clinical Guidelines on the evaluation of monoarticular pain in 1996.  With more discussion and narrowing of possible etiologies, there was question of whether a previous episode a few months ago was, in fact,  an acute gout flare treated with steroids, however, not proven by joint aspirate analysis. Once again, presumed gout was ultimately the clinical diagnosis  for this admision. However with all of the patient’s comorbidities (CRI, DM,), the team confronted many dilemmas  on how to approach her therapy.

Highlights of the discussion included the following:

*Incidences of acute gout episodes and the role of serum urate levels during these attacks (NEJM review).

*Deeper review of how various conditions may proceed to complications in the patient’s care (i.e. oral steroids in the diabetic patient)

*Furthermore,  exploration of the differences in presentation in an elderly patient with gout and review of alternative therapies (interesting article found here).