Requiem for gouty nephropathy

Abstract

A 74-year-old black man was admitted to the Philadelphia Veterans Administration Medical Center because of pain in several joints. The patient was retired from a rubber factory. He had smoked cigars but stopped 8 years prior to admission. He did not drink alcoholic beverages and denied 'moonshine' ingestion. He had been well until 24 hours prior to admission, when he developed increasing pain and swelling in his right great toe, followed by similar pain in both ankles and in his right elbow. He denied chills or fever, and he gave no history of recent infections, trauma, or dysuria. He reported several similar episodes of right foot pain, especially at night, over the last 3 or 4 years, but these attacks had always subsided within 24 to 48 hours and had never involved other joints. He also gave a history of 'degenerative arthritis' of the knees, for which his own physician had given him ibuprofen, 600 mg 3 times a day. The patient had been known to have hypertension for about 10 years, and he was taking furosemide, 40 mg daily, and clonidine, 1 mg daily. He had suffered a 'small stroke' in 1978 with minimal residual right-sided weakness. He was unaware of any renal disease, and there was no family history of gout, hypertension, diabetes mellitus, or renal disease. At the time of admission, he was febrile (temperature, 102.8°F orally). Blood pressure was 140/90 mm Hg; pulse, 96 and regular. He was an obese, alert man complaining of pain in his ankles, foot, and elbow. Funduscopic examination showed arteriovenous nicking. The cardiac apical impulse was moderately displaced to the left, and there was a grade II/VI holosystolic murmur radiating to the axilla. The right foot was swollen, red, and tender, especially over the first metatarsophalangeal joint. There was also tenderness and swelling in both ankles as well as in the right elbow. No tophi were present. Except for a mild motor weakness in the right upper extremity, the rest of the physical examination was normal. Initial laboratory tests revealed the following: hemoglobin, 14.7 g/dl; hematocrit, 45.7%; white blood cell count, 14,700/mm3 with 85% polys, 9% lymphocytes, and 6% monocytes. Sodium was 144 mmol/liter; potassium, 3.7 mmol/liter; chloride, 102 mmol/liter; and CO2, 24 mmol/liter. Blood glucose was 135 mg/dl; BUN, 20 mg/dl; and creatinine, 2.5 mg/dl. Uric acid was 10.2 mg/dl; calcium was 9.0 mg/dl. Urinalysis revealed a pH of 5.0, 1+ protein, negative glucose, and negative heme; microscopic examination disclosed a few hyaline casts and no crystals. Chest x-ray was normal except for slight cardiomegaly. An electrocardiogram was normal. Arthrocentesis on both ankle joints yielded thick fluid. White blood cell counts of the joint fluid were 68,000/mm3 and 89,000/mm3, with 93% polys. Gram stain was negative. Both fluids were loaded with monosodium urate crystals outside and within the polymorphonuclear leukocytes. The patient was treated with intravenous colchicine, followed by oral colchicine. Ibuprofen was discontinued because of the renal insufficiency. A cephalosporin antibiotic was administered for 24 hours until cultures were found to be negative. Because the fever and joint pain continued for 24 hours with the patient taking colchicine, he was given a short course of prednisone; this regimen produced quick resolution of the joint symptoms. After ibuprofen was discontinued, serum creatinine remained at 2.4 to 2.6 mg/dl. On the seventh hospital day, while he was ingesting a normal diet, creatinine clearance was 37 ml/min, and a 24-hr urine collection revealed a total uric acid excretion of 590 mg. Renal ultrasound showed no hydronephrosis, no stones, and normal-sized kidneys. The patient was discharged with plans to begin taking allopurinol as an outpatient.