64-Year-Old Man With Draining Wounds on His Toes

January 26, 2015

All of the signs pointed to osteomyelitis with sepsis. But further examination pointed to consequences of poorly controlled gout.

Shah D, Mohan G, Flueckiger P, et al. Polyarticular Gout Flare Masquerading as SepsisAmerican Journal of Medicine 2015. Online: January 20, 2015. doi: http://dx.doi.org/10.1016/j.amjmed.2014.12.025

This brief case study is a cautionary tale about poorly managed gout and a reminder of a misleading consequence.

The patient, a 64-year-old African American man with a history of chronic tophaceous gouty arthropathy had four days of severepain in his left foot and ankle associated with fever, fatigue and weakness.

Prurulent-appearing material drained from open wounds on the first and fourth toes of the left foot. Plain film radiology of the left foot suggested osteomeyelitis of the first toe.

Broad-spectrum antibiotics and intravenous fluid resuscitation had little effecton the presumed sepsis, however.

Magnetic resonance imaging of the left foot found no clear evidence of the condition. Further, the exudates proved negative for microorganisms.

Polarized light microscopy revealed bireferingent urate crystals.

Prednisone quickly resolved the fever, tachycardia and pain. (Antibiotics were discontinued.)

Final diagnosis: Systemic inflammatory response syndrome (SIRS) masquerading as sepsis.

Microscopic examination of exudates or synovial fluid is key to making the distinction.