01/29/2016    

Gout-Like Symptoms Unresponsive to Therapy

A 64 y/o white male who is a liver transplant
patient and on multiple anti-rejection drugs
was seen in my office with a painful red, hot,
swollen left foot with the symptoms
concentrating along the left 1st MPJ. He states
that he had gout 10 years ago. He takes
allopurinol 300mg. X-rays were negative for any
bony destruction around the left 1st MPJ.

We treated him for a acute gout with a
cortisone injection (1x) and colchicine 0.6mg
po x 3 days. He was provided an Unna boot
application which was repeated 2-3x over a 10
day period until his edema pain and redness
resolved. He was negative for a DVT. He healed
uneventful on the left foot until he presented
with same problem on the right foot and he was
treated the same way, but has not gotten
better.

The patient stated he was seen by a general
surgeon prior to seeing me for his R foot
problem who performed a venous Doppler exam
which was negative. When he had a similar
problem in the L foot a venous Doppler was
performed on that side and it was negative as
well.

This patient also had labs were taken (CBC-
diff, UA, CMP, ESR, and CRP) regarding the R
foot problem not resolving and they were all
normal (slight elevation of liver enzymes and
ESR). His WBC was also normal along with with
uric acid level which was 2.2 mg/dcl. As
stated, he had a similar problem on the
opposite foot and was treated with cortisone
injection, colchicine 0.6mg for 3 days, Unna
boot and his MD increased his dose of
Allopurinol 300mg from QD to BID.

He was referred to and seen by a rheumatologist
who could not make a diagnosis of gouty
arthropathy in the right foot as we had
suspected like on the left foot. He recommended
an MRI of the right foot. It was performed and
revealed no abnormalities present around the R
1st MPJ or first metatarsal (based on the
report provided by a radiologist).

We are at a loss to exactly why the R foot is
not responding the same way. He has pain and
swelling increased at night with no relief
until morning. he uses an ACE wrap and Unna
boot to control the swelling and pain. He has
no signs of vascular abnormalities in either
lower extremity or foot. He cannot take
macrolides (Biaxin) for cellulitis due to
potentiating the anti-rejection drugs and
possible kidney failure.

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