Abstract
Case study
A 42-year-old man presented with an acutely swollen left hand. The swelling had developed over night, quickly becoming red, warm and painful to touch. He recalled having had a painful swollen toe several months earlier. He drinks at least two beers every night.
Acute gout
Acute gout presents as an acutely swollen, red, tender joint and tends to affect the first toe (cool part of the body), ankles, feet, knees, fingers, wrists and elbows. However, any joint can be affected, especially osteoarthritic joints. Gout may also present as polyarticular swelling and with hand and feet oedema in the elderly (Badlissi, 2019).
Gout is caused by the deposition of urate crystals in the joint. Urate is a product of purine metabolism. Purines are present in seafood, meat and alcohol, or endogenously produced as a result of haematological cancers or chemotherapy. Other risk factors include obesity, hypertension and diuretic therapy.
Diagnosis is by joint aspiration to confirm the presence of monosodium urate crystals or by fulfilment of six or more of the American College of Rheumatology criteria (Neogi et al., 2015).
First-line treatment of acute gout is with maximum dose non-steroidal anti-inflammatory drugs (NSAIDs) along with proton pump inhibitor for gastric protection. An alternative to NSAIDs is colchicine, up to 3 mg a day. Corticosteroids (intra-articular/oral/intramuscular) are an effective alternative treatment and can be used for a short period of time (Badlissi, 2019).
Long-term management of gout includes weight loss, dietary modification and urate-lowering therapy in those with chronic symptoms or joint damage. Allopurinol can be started 14 days after an acute exacerbation at a dose of 100 mg/day and increased over weeks or months until the serum urate level is <360 micromol/L. NSAIDs or colchicine can be taken prophylactically during up-titration of allopurinol (NICE, 2018). In patients not able to tolerate allopurinol, febuxostat can be considered, although it is associated with an increased risk of cardiovascular death and all cause mortality (White et al., 2018).
In this case the patient was treated with naproxen and underwent a joint aspiration that confirmed the diagnosis. He was later started on life-long allopurinol and encouraged to reduce his alcohol intake.
