It was The Gout

In the last post, I left you guessing and here's the answer. I'm sure some of you already knew what it was based on it's toothpasty-chalky-white appearance. It's what we call tophaceous gout meaning high levels of uric acid in the blood that eventually crystallizes into the tissues (tophi). Many of these are painless and for some reason or another, end up in the joint spaces like elbows, hand and foot joints and even the ear. It is an inflammatory arthritis (not contagious) and in the early stages it accounts for unexplained single-sided joint pain. 

It must be gout season because I was getting a cluster of patients with unexplained reasons for pain in one foot that became red, hot and swollen for apparently no reason. No falling, tripping, trauma, or bug bites. Or gonorrhea. Go ahead, Google that one. My last patient was a young male who went on a camping trip and admitted to binge drinking. He was in his late 30's, his history was vague, he wasn't sure if he kicked something or someone but the pain persisted for several days and was getting more intense. (Risk factors for a gouty flare up explained better by Mayo Clinic.)

So if you refer back to my last few post called What you should know about foot pain in diabetics with neuropathy, the presentation of acute gout and Charcot foot is very similar.  How do I determine what it is? (And this is the "art" or medicine, conjuring up ideas and linking the webs of associations from all of our medical school training)...x-rays. Charcot will show obvious bone break down while gouty tophi bone destruction is hardly seen at all and you really have to squint to see the "joint mouse" (as it is described) with tiny flecks of bone in the joint from long-term gout. It can also look like a bunion. (I promise a bunion post will come soon!)

This patient came to me as a second opinion because a previous doctor tried to aspirate it (usually reserved for something more fluid-y) and then a steroid injection in hopes to shrinking it and reducing pain but it only got bigger. So you saw what I did, I scooped the crystals out of the patient and he went on his way doing whatever it is that he does. 

X-ray of 2 different problems but similar clinical presentations:

 Left: gouty tophi shows on xray as a soft tissue density but the bone it not affected much (some squinting will produce bone cysts & bone erosion at the edges). Right: a bunion that protrudes in a similar manner to the tophi but it's a structural problem with the joint going the wrong direction. 

Left: gouty tophi shows on xray as a soft tissue density but the bone it not affected much (some squinting will produce bone cysts & bone erosion at the edges). Right: a bunion that protrudes in a similar manner to the tophi but it's a structural problem with the joint going the wrong direction. 

Feel free to submit your questions, perhaps they will become the next post!