Medical Grand Rounds Clinical Vignette February 18th, 2009 Deena

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