Monday, November 17, 2008

The Hot Toe

By Richard P. Holm MD

It was 1972 and I was a green sophomore med student spending my summer shadowing a doctor in Watertown. As soon as we walked into the patients room, my hero-teacher told me the patient was suffering from an acute attack of gout. 

The crusty old German doctor explained we were seeing the classic signs of inflammation. He said that the great Celsius, a physician living in the first century, described inflammation with four cardinal signs and the definition still applies. 

"In Latin it's rubor, calor, tumor, dolor," is what he said. "Commonly inflammation means infection, but in this case there is no infection. Rubor is redness, calor is heat, tumor is swelling, dolor is pain, and add to that loss of function." There it was, a red, hot, swollen, painful toe. And the patient said, "It hurts so bad I can't stand for my wife to look at it." 

The patient was a 45 year-old man with a tendency to drink too much, a prior experience of similar bouts of severe single joint inflammation, and he came from a family many of whom also experienced this same condition. He was moderately over-weight, quite sedentary, and was taking a water-pill for high blood pressure.

"This is the classic picture of gout," my teacher told me. "His body suffers from too much uric acid, partly because of dehydration from the water pill, partly because of his weight and lack of exercise, maybe a little from eating too much protein, but mostly because he inherited the tendency. Too much uric acid causes the formation of needle shaped crystals in the joint fluid, and then comes inflammation."

"We need to treat the inflammation first, and then later get at reducing the uric acid level, or he may destroy his joints, develop kidney stones and destroy his kidneys," he instructed.

The complex treatment of gout made our patient better. It was the perfect lesson from a great teacher.

Take home lesson:
1. Inflammation is characterized by redness, heat, swelling, pain, loss of function, and can be due to reasons other than infection.
2. Gout most often presents as recurrent episodes of a severely inflamed single joint, most often involving the big toe but it can effect other joints as well;
3. This condition results from the formation of uric acid crystals in joint fluid;
4. Gout can progress to destruction of joints and kidneys, so it needs proper treatment.

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