Case: My foot hurts

Posted on Oct 5, 2010 in Case Studies | 4 comments

Case: 57-Year-Old Woman With Joint Pain and Swelling

 

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“I hate getting old! Over the past few days, my foot hurt so bad that I had to cancel my aerobics class …”

Case: Mrs. Brady is a 57-year-old woman who presents to your office as a new patient. Her chief complaint is of severe pain and swelling in her right foot over the past 2 days that is based at the right great toe. She states that she has had pain “off and on” over the past couple of weeks that has interfered with her ability to play tennis or teach aerobics. 

Patient is a married mother of 4 who works as a high school math teacher. Her husband and children are all alive and well. 

Her past medical history is positive for hypertension, hyperlipidemia, diabetes, osteoarthritis of the knee, and recent urinary tract infection (UTI). She has no drug allergies and is physically active at least 4 times per week. Medications: HCTZ, metformin, a statin, trimethoprim-sulfamethoxazole for UTI and occasional NSAIDs for joint pain. She has undergone several cortisone injections to the knee over the past 18 months with no complications. Last injection was 3 days ago. She denies any medication allergies. 

Family history is positive for heart disease (father) and arthritis (mother).  

Physical examination:
Fit, athletic woman in acute distress
Weight 135 lbs., Temp 99.7 degrees F, Height 5’7”, BP 125/68

Extremities: Right knee is red and slightly swollen with no impaired range of motion. Right foot is remarkable for swollen, hot, and tender right great toe. The toe is excruciatingly sensitive to touch. No other joint inflammations noted and there are no apparent tophi. 

Labs indicate a uric acid of 8.1 (normal = 2.4-6.0).

Although gout is less common in women than in men, the incidence increases in postmenopausal women.[1] Based on the laboratory data, medication history, and physical examination, you make a diagnosis of gout. Because HCTZ can worsen hyperuricemia and precipitate gouty attacks,[2,3] you switch her to losartan, which has been shown to lower uric acid levels. You start her on colchicine 0.6 mg 2 tablets immediately, followed by 1 tablet in 1 hr or 1 tablet TID for 1 to 2 days. She is instructed to call the office in 3 days and report any change or improvement in symptoms. 

Mrs. Brady calls back in 2 days. She reports that although the pain and swelling in her toe have improved dramatically, now her knee is “huge” and very painful. Range of motion is significantly impaired. She is instructed to come to the office immediately.

On exam, temperature is 100.2 degrees F. The right knee is acutely swollen. Patient is in obvious pain and has extremely limited range of motion to both active and passive attempts. Great toe is no longer painful, with decreased swelling and redness.

How would you proceed?

Published on October 5, 2010
Updated on October 12, 2010

Discussion

As Mrs. Brady has diabetes, recently undergone cortisone injections, and been treated for a urinary tract infection, it is possible that she has septic arthritis superimposed on gout. 

Septic arthritis is a rather rare but important infection of the joints, which is sometimes seen in patients with diabetes. Bacteria enter the joint through the synovial membrane and migrate into the synovial fluid. Any microbial pathogen can cause septic arthritis, although staphylococci and streptococci are the most common of the nongonococcal bacterial isolates.[4] In the majority of cases, septic arthritis occurs most commonly in large peripheral joints such as the knee, which accounts for approximately 50% of cases.[5] 

In Mrs. Brady’s case, the original source of the bacteria may have been her recent UTI, or the result of bacteria introduced directly into the knee at the time of her corticosteroid injection; septic arthritis following intra-articular steroid injections is a rare but well-recognized complication.[6,7] Her diabetes may also have been a factor.

The diagnosis for septic arthritis is confirmed by positive synovial fluid examination including a white count, a Gram stain, and a culture. This may require an urgent referral to a rheumatologist. In addition to drainage of the septic joint, rapid administration of IV antibiotics is paramount. It is important to obtain the synovial sample and blood cultures prior to commencement of IV antibiotic treatment. However, treatment should not be delayed until the gram stain and/or culture are identified and most patients will respond to IV oxacillin or nafcillin in combination with IV ceftriaxone, cefotaxime, or ceftizoxime.[8]

As the swelling and pain in Mrs. Brady’s toe has greatly diminished with the initiation of colchicine, the initial diagnosis of gout was likely correct. Since she has no prior history of gout and her symptoms have abated, no additional treatment is indicated at this time.[9] The patient should be instructed to monitor her symptoms and to call the office immediately if the symptoms recur,  at which time, further decisions can be made about longer-term prophylaxis and/or therapy with urate lowering agents.

References

1. Becker MA, Ruoff GE. What do I need to know about gout? J Fam Pract. 2010;59(6 Suppl):S1-S8.
2. Emmerson BT. The management of gout. N Engl J Med. 1996;334(7):445-451.
3. Würzner G, Gerster JC, Chiolero A, et al. Comparative effects of losartan and irbesartan on serum uric acid in hypertensive patients with hyperuricaemia and gout. J Hypertens. 2001;19(10):1855-1860.
4. Gupta MN, Sturrock RD, Field M. Prospective comparative study of patients with culture proven and high suspicion of adult onset septic arthritis. Ann Rheum Dis. 2003;62(4):327-331.
5. Goldenberg DL. Septic arthritis. Lancet. 1998;351(9097):197-202.
6. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478-1488.
7. Charalambous CP, Tryfonidis M, Sadiq S, et al. Septic arthritis following intra-articular steroid injection of the knee—a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clin Rheumatol. 2003;22(6):386-390.
8. Aslam S, Darouiche RO. Antimicrobial therapy for bone and joint infections. Curr Infect Dis Rep. 2009;11(1):7-13.
9. Doghramji PP, Edwards NL, McTigue J. Managing gout in the primary care setting: what you and your patients need to know. Am J Med. 2010;123(8):S2.