         |
    |
 |
|
 |
Test Your Knowledge #2-How would you manage gout in a patient with congestive heart failure? by Fredrick M. Wigley, M.D. |
||
|
|||
|
A.L. is a 55 year old Caucasian male admitted to the Johns Hopkins Hospital for intensive management of congestive heart failure. The patient has end-stage cardiomyopathy and his admission is prompted by the expectation of impending heart transplant. His primary care physician has treated him for over 10 years for "gout". Treatment has consisted of the use of indomethacin and oral colchicine during acute attacks and no therapy between attacks. The patient's arthritis is characterized by the sudden onset of intense pain, redness and swelling in the affected joints which include the great toes, midfeet and ankles. His first few attacks occurred 1-2 years apart; however, in the last year, his attacks have been occurring monthly. His family history is remarkable for the diagnosis of gout in his brother and father.
In reviewing the patient's chart, you note that his serum uric acid in the past few years has averaged 10-14 mg/dl. His creatinine has averaged 1.5 mg/dl. He has never had a joint aspiration, nor has he ever had a 24-hour urine collection for uric acid. On this admission, his serum uric acid is 20 mg/dl and his creatinine is 1.8 mg/dl. He now requires high doses of furosemide and is on dobutamide intravenous infusion for management of his congestive heart failure. As the rheumatology consultant, you are called to advise regarding management of a resolving gout attack in the patient's right foot. You ascertain that the patient's attack is several days old and getting better spontaneously and that it mimics all of his previous attacks. On his exam, you note discrete soft tissue nodules with a yellowish discoloration on the pinna of the right ear and over the dorsum of his left fifth finger. None of the joints are acutely inflamed; however, the 1st MTP and tarsal-metatarsal joints of the right foot are mildly swollen and mildly tender to palpation and movement. He is having difficulty ambulating because of discomfort in the right foot.
1. The available data for the diagnosis of gout are:
|
|||
|
|||
|
|
|||
>