Just a quick one, but I’m trying to include a bit more clinical content on my blog. Let’s see how it goes!
An 84 year old woman has an 8 week history of gradually worsening tender lumps on her fingers, R>L. She has not had anything like this previously. She has a history of AF, angina, OA and previous AAA repair. Her medications include warfarin, amiloride hydrochlorothiazide, celecoxib, paracetamol, felodipine, GTN spray, tramadol, allopurinol and she is wearing a buprenorphine patch.
1. What is the most likely cause?
2. What are some differential diagnoses?
3. What is the management?
Answer in the comments below, discussion to follow next week!
Thanks to my lovely Granny for letting me photograph her fingers!
Thanks to everyone who commented below and sorry about the delay in updating the post with discussion. I’ve been having some technical difficulties in establishing a reliable internet connection in my new posting in Albany. Particular thanks to my old med school chum Dr Andy Lim who is an advanced trainee in rheumatology and provided a great and comprehensive answer below and also directed me to some useful resources.
Here’s my summary of the learning points:
1 & 2. All of the commenters mentioned the likely suspects with regard to subcutaneous nodules including:
- Heberden’s nodes of OA – but less likely to occur over such a short time frame and be tender
- Rheumatoid nodules – which are more likely to occur on the PIP and MCP joints rather than the DIPs in the hands
- Psoriatic arthritis – but there is no history of rash in this case
- Pseudogout – but more likely in larger joints
- Gouty tophi – I think the general consensus is that this is the most likely culprit here!
UpToDate tells me that there are two main subgroups of patients who develop tophaceous gout. One group is represented by men with risk factors of excess alcohol consumption, diuretic use and poor compliance to medication. The second group is (mainly compliant) elderly women with the triad of underlying osteoarthritic finger joints, diuretic use and impaired renal function. We can probably assume that Granny Wilson ticks most, if not all of those boxes!
3. I refer you to Minh Le Cong’s recent foam4gp presentation which summarizes nicely the management principles of acute and chronic gout management and links to further reading. http://foam4gp.com/2013/03/24/gout-in-6-minutes-for-the-gp/#more-101
I think that this case highlights a few particular management issues which I’ll just briefly mention:
- Oldies are not always the best historians and may well be on multiple medications that they don’t know the reason for. This is a common challenge when dealing with patients who may be away from their usual clinic and it sometimes requires some lateral thinking to get to the bottom of the relevant clinical background. A quick phone call to the usual treating doctor may be in order if something doesn’t add up.
- Treat gouty tophi as per chronic gout with uric acid lowering agents. Start allopurinol at 100mg/day and increase 50-100mg monthly, while keeping a close eye on uric acid and LFT/UEC. Aim to get the uric acid <0.36. Cover with colchicine low dose until target is acheived.
- Treat painful inflamed gouty tophi as per acute gout, eg with NSAID or if contraindications (eg angina as with this case) colchicine in the low dose regimen, ie 2x 500mcg colchicine stat, followed by a further 1x500mcg 1 hour later, and do not repeat for at least 3 days. The old days of bombarding the patient with colchicine every few hours until they got the runs are over. Short course of prednisolone may also be useful.
- Stop any precipitating medications – in this case, the diuretic is probably doing more harm than good.
- Look to lifestyle factors. As it happens, Granny is very partial to a big feed of seafood and just the day before the photos were taken we had dined on crabs, prawns and crayfish. I may have to have a word with her about cutting down on the crustaceans which I don’t think will impress her very much!
Some further reading:
- EULAR Evidence Based Guidelines for Gout: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1798308/