Transcript MGR Case Report - Clinical Correlations

Medical Grand Rounds
Clinical Vignette
February 18th, 2009
Deena Altman, M.D.
Chief Complaint
51 year old female presents with three
days of pain, swelling, warmth, and
redness in her elbows, hands, wrists,
and knees.
History of Present Illness
The patient was diagnosed with gout and
osteoarthritis, affecting multiple joints, well over
10 years prior to admission.
She suffers from chronic joint pain that is
adequately controlled with as-needed nonsteroidal anti-inflammatory medications.
However, over the last three days, her pain
acutely worsened, limiting her from any
movement.
She was carried into the hospital by her family
members.
History
Past Medical History:
– Tophaceous gout
– Osteoarthitis
– Hypertension
– Former intravenous drug abuse
– Hepatitis C
– Chronic renal insufficiency
Past Surgical History:
– none
History
Social History: Lives with daughter. Drinks ½
pint of brandy daily. Occasional cannabis abuse.
Not sexually active.
Family History: Non-contributory
Allergies:
No known drug allergies
Medications:
Lisinopril 5mg Daily
Nexium 40mg Daily
Multivitamins
Review of Systems:
– Subjective chills over the past 3 days. Remainder of
review of systems negative.
Physical Exam
General: middle-aged female in acute distress, Alert and
Oriented to person, place and time.
T:98.4 F BP:115/76 HR:110 RR:18 O2:99%RA
Musculoskeletal exam:
Elbows with bilateral swelling at olecranon bursae
with tophi.
Left wrist with swelling and warmth.
Decreased range of motion, warmth, redness in left
2nd –4th MCPs and PIPs.
Right hand with Heberdens and Bouchards nodes.
Bilateral knees with warmth and effusion, full range
of motion.
The remainder of the physical exam was normal
Laboratory
WBC 17.8, 84% Neutrophils
Hemoglobin 8.5 g/dL (13.5-16.5), MCV 97
Creatinine 1.5
Alkaline phosphatase 368
Coagulation studies normal
ESR 120 , CRP 223
Uric acid 8.5
Rheumatoid factor negative
Imaging
Chest X-Ray: Normal
Elbow X-Ray: bilateral effusions, soft tissue
swelling, lateral osteophyte
Wrist X-Ray: no fracture, mild soft tissue
swelling, osteopenia
Lumbar X-Ray: mild multilevel discogenic
degenerative disease
Differential Diagnosis
Septic Arthritis
Severe Gout Flare
Hospital Course
The patient was admitted and started on IV
Ceftriaxone and Vancomycin for suspicion of
septic arthritis.
A left knee joint aspirate was obtained which
revealed viscous fluid. Gram stain and culture
were negative. Microscopy revealed copious
extracellular and intracellular urate crystals.
Her antibiotics were stopped and she was
started on oral prednisone for gouty flare and
received bilateral knee joint injections with
prednisone.
Hospital Course
She did not respond to escalating doses of oral
steroids. Only when she was switched to high
dose intravenous steroids did she begin to
improve.
Colchichine was initially held due to concern of
her chronic renal insufficiency. It was started
when the creatinine remained stable.
Patient was discharged to an acute rehabilitation
center.
Follow-up
Patient has been doing well in acute inpatient
rehabilitation facility with a slow oral prednisone
taper.
Final Diagnosis
Acute, severe Gout involving multiple
joints