GOUT Case Study

7/30/2019 GOUT Case Study

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GOUT CASE STUDY(A rare case of a 50-year-old white woman with a history of chronic gout and rheumatoid arthritis who presented

with intradermal tophaceous gout.)

A 50-year-old white woman with sever anemia was transferred from an outlying medical center to the OklahomaState University (OSU) Medical Center in Tulsa.

Chief Complaint:

Shortness of breath and sever fatigue

History of Present Illness:JC is an overweight 80-year old white female who is presented to the ER for experiencing an increased

shortness of breath over the past month. She is also experiencing an increased swelling of the ankles and feet over the past two weeks. She feels easily fatigued and has been waking up the past couple of nights “trying to catch her

breath”. She has been using several pillows to prop herself up at night. These symptoms are indications ofparoxysmal nocturnal dyspnea (PND.)

Past Medical History:Rheumatoid Arthritis (diagnosed 16 years ealier)GoutDepressionHypertension

Past Medication Therapy:Adalimumab inj. for RA (40mg every other week)Allopurinol tab. for Gout (300 mg twice daily)Amitriptyline HCl tab. for Depression (150mg/dl at bedtime)Clonidine tab. for Hypertension (0.2mg daily)Acetaminophen for Pain (taken as needed)Admin of Packed RBC 4 units (for anemia) just before she was transferred to the OSU Medical Center

Physical Exam:V/S: Temp: 102.9oF HR: 105bpm BP: 160/96mmHg RR: 24 breaths per min.G/S: Patient is obese, alert and oriented and in no acute distress.

Lab Exam Results:Creatinine Value: 1.8mg/dlErythrocyte Sedimentation Rate: 106mm/hWBC Count: 15,200 per microlitreHemoglobin: 9.6mg/dl

She had multiple pustules with a yellow center on her abdomen and fingers (Figure 1.) Her wrist were bilaterally

swollen and tender, and she complained of decreased range of bilateral motion in her metacarpophalangeal joints.She also had bilateral swelling and pain in her knees.



Radiographic scans of the patient’s hands revealed bilateral juxta-articular osteopenia involving themetacarpophalangeal regions and bilateral symmetric radial and ulnar carpal joint space loss with associated erosivechanges consistent with RA (Figure 2.)

The first metacarpophalangeal joint in the patient’s left hand was subluxated and loss of the ulnar styloid wasvisible. Radiographic scans of the patient’s feet also uncovered symmetric joint space narrowing with osteopenia

(Figure 3.)

A wet mount specimen with polarized light microscopy of the punch biopsy for an adominal skin lesion revealedmonosodium urate crystals, which are indicative of tophaceous gout (Figure 4.)

The patient’s daily dose of amitriptyline was changed to 75 mg—50% of the dose prescribed to her at home—

because of her previous noncompliance with prescribed medications. On day 2 of admission, a gastroenterology

consultation was obtained and an esophagogastroduodenoscopy was performed, which showed mild antralgastritis. The patient was administered pantoprazole sodium, 40 mg/d, for gastritis and severe anemia and toprevent gastrointestinal bleeding. The patient was also administered ceftriaxone sodium, 1 g/d, as empiric therapy asa result of the elevated white blood cell count and fever. All other medications were continued as previouslydescribed. Because the patient had a history of gout and RA as well as an elevated serum creatinine level,consultations were obtained from the rheumatology and nephrology services 4 days after admission. Laboratoryresults from these consultations revealed a rheumatoid factor of 20 IU/mL; reticulocyte count, 3.08%; lactatedehydrogenase, 263 U/L; serum uric acid, 6.8 mg/dL; 24-hour urine protein, 2074 mg; and 24-hour urine uric acid, 432mg. The low rheumatoid factor value indicated seronegative RA. The patient receivedprednisone, 40 mg/d, andcolchicine, 0.6 mg/d, combination therapy for her rheumatologic conditions. Although the patient’s uric acid levels

were within the normal range, tophaceous gout was also diagnosed as a result of the presence of monosodium

urate crystals. In addition, the patient’s elevated lactate dehydrogenase level and reticulocyte count indicatedhemolytic anemia. A Coombs test was not performed because the patient had already received corticosteroids.

Results from a peripheral smear suggested normocytic anemia with granulocytosis and thrombocytosis. However,this result may be attributed to the fact that the smear was performed after administration of steroids and packedred blood cells. The patient was discharged 6 days after admission in stable condition. She had decreased shortnessof breath, fatigue, and joint pain, as well as improved but not completely resolved tophi lesions. Because of the highserum creatinine level and the patient’s noncompliance with her previous home medication regimen, the daily doseof allopurinol was decreased to 100 mg. Similarly, colchicine (0.6 mg/d) was used as an acute therapy and as aprophylactic agent with the “initiation” of allopurinol therapy (ie, the colchicine was used as if the patient was juststarted on allopurinol therapy in an acute flare). The patient’s other medications on discharge included prednisone,40 mg/d for 2 weeks, and weekly doses of alendronate, 70 mg, and etanercept, 50 mg.



Questions:

1. What is the normal uric acid levels in men and in women?- Answer: 7mg/dl in men; 6mg/dl in women

2. What was the reason why the dosage of her past medications like allopurinol and amitriptyline decreased?- Answer: Because of noncompliance with her medication regimen

3. What is the underlying cause why a Coomb’s test cannot be performed when patient is receivingcorticosteroids?

4. Presence of______ is an indication of a tophaceous gout.- Monosodium urate crystals

5. What patient counselling points would you give the patient?- Answer:

o Work on losing weight and maintaining a healthy diet appropriate for her conditiono Find ways to follow through on her medication regimen

6.

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GOUT Case Study