Case history
Case history #1
A 54-year-old man complains of severe pain and swelling in his right first toe that developed overnight. He is limping because of the pain and states that this is the most severe pain he has ever had ("even covering my foot with the bed sheet hurts"). He has had no previous episodes. His only medication is hydrochlorothiazide for hypertension. He drinks 2 to 3 beers a day. On examination, he is obese. There is swelling, erythema, warmth, and tenderness of the right first toe. There is also tenderness and warmth with mild swelling over the mid foot.
Case history #2
An 85-year-old man presents with several days of swelling and severe pain in both hands limiting his ability to use his walker. He has a history of gout but has not experienced these symptoms before. On examination, he has a temperature of 100.1°F (37.8°C). There is diffuse warmth, mild erythema, and pitting edema over the dorsum of both hands. There is tenderness and limited hand grip bilaterally. There are multiple nodules around several of the proximal interphalangeal and distal interphalangeal joints, and effusion and tenderness in his left olecranon bursa with palpable nodules.
Other presentations
Gout may also present as acute bursitis, especially in the olecranon and prepatellar bursae. Chronic tophaceous gout may cause inflammatory destructive polyarthritis. This usually occurs in people with a long-standing history of attacks (mean 10 years) and with higher uric acid levels.[Figure caption and citation for the preceding image starts]: Chronic tophaceous gout showing nodules in the hands, elbows, legs, buttocks, and abdominal wall (arrows)Adapted from BMJ Case Reports 2009 [doi:10.1136/bcr.03.2009.1668] Copyright © 2009 by the BMJ Group Ltd [Citation ends].
[Figure caption and citation for the preceding image starts]: Chronic tophaceous gout showing nodules in periarticular structures and arthritisAdapted from BMJ Case Reports 2009 [doi:10.1136/bcr.03.2009.1668] Copyright © 2009 by the BMJ Group Ltd [Citation ends].
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