Case 29: Infected Finger
Tuesday, September 27th, 2011Author: Dr Ian Stell
This 83 year old was referred by her GP. She was in nursing home with dementia. Her finger had been noticed to be red and swollen for a month. The GP had given antibiotics, but it had not improved. He was concerned about the presence of osteomyelitis, and wanted an x-ray. She had no other significant medical history.
She was combative, and difficult to examine. Her finger was swollen, irregular in shape, and with two ulcerated areas.
An x-ray was taken (with some difficulty!):
1. What do you think is the cause?
Click to see the answerThis is chronic tophaceous gout. The knobbly appearance, with ulceration over the tophi is classical. The x-ray shows a typical punched-out lesion.
2. How could you establish the diagnosis?
Click to see the answerThe diagnosis can be conformed from an aspirate or scrapings from the toph for microscopy for crystalsi. Serum uric acid may be raised, although there is not a good relationship between serum uric acid levels and acute gout. X-rays (as here) can be diagnostic.
3. Management?
Click to see the answerGenerally acute attacks are managed with NSAIDS (eg diclofenac 50mg TDS), colchicine (0.5mg every 2 hours until GI toxicity develops), or failing these, prednisolone (eg 15mg daily for 5 days). Prophylaxis can be with allopurinol (beware precipitation of acute attacks), low-dose colchicine or uricosuric agents. Diet changes may also help. Chronic tophaceous gout requires measures to reduce urate; and may also require surgical excision of tophi in order to manage skin ulceration.