I read this article with interest. I have just been dealing with a relevant case indicating difficulty in differential diagnosis. This was a 52 year old woman who had been in hospital for over a week under the care of general physicians with a diagnosis of a possible infected knee joint and prepatellar bursa and cellulitis of the lower leg. There was no fever at any time. The CRP was 145 mg/L and the WBC was 13.0 with a neutrophilia. Urate was normal at 0.09 mmol/L. Blood cultures were negative. Fluid was not withdrawn from the knee or the bursa. She had been seen by orthopaedic surgeons but not by a rheumatologist. She was treated with intravenous clindamycin with no significant effect, and after her discharge, still on oral antibiotics, I was called in to see her. The history was of a painful knee developing over a day to extreme pain with a lot of swelling, with no injury or obvious cause, followed within a day by painful swelling of the whole of the lower leg with skin erythema. On examination the knee and prepatellar bursa were swollen and painful, there was a tender popliteal cyst, and the lower leg was very swollen and erythematous.
As she told me the story I realised she was describing an acute attack of gout with a burst popliteal cyst, and I then found that her father had gout. Doppler studies after her discharge had ruled out a deep vein thrombosis. All the blood test results are compatible with acute gout, including the normal urate.
The pain and swelling of the knee rapidly resolved on treatment with diclofenac 50 mg four times daily (with a stomach protective), and the swelling and erythema of the lower leg gradually went away with the help of elevation and an elastic stocking. Strikingly, the skin over the front and sides of the knee peeled off massively during recovery, which of course is typical of gout and would not be expected after an infection.
Acute arthritis is quoted as a possible differential diagnosis in the article, and this case demonstrates that acute gout must certainly be considered.
Patient consent obtained.
Competing interests:
No competing interests
01 September 2012
Michael F. Grayson
Consultant rheumatologist
Private practice, Royal National Orthopaeduc Hospital
Royal National Orthopaedic Hospital, 45 Bolsover Street, London W1W 5AQ
Rapid Response:
Re: Diagnosis and management of cellulitis
I read this article with interest. I have just been dealing with a relevant case indicating difficulty in differential diagnosis. This was a 52 year old woman who had been in hospital for over a week under the care of general physicians with a diagnosis of a possible infected knee joint and prepatellar bursa and cellulitis of the lower leg. There was no fever at any time. The CRP was 145 mg/L and the WBC was 13.0 with a neutrophilia. Urate was normal at 0.09 mmol/L. Blood cultures were negative. Fluid was not withdrawn from the knee or the bursa. She had been seen by orthopaedic surgeons but not by a rheumatologist. She was treated with intravenous clindamycin with no significant effect, and after her discharge, still on oral antibiotics, I was called in to see her. The history was of a painful knee developing over a day to extreme pain with a lot of swelling, with no injury or obvious cause, followed within a day by painful swelling of the whole of the lower leg with skin erythema. On examination the knee and prepatellar bursa were swollen and painful, there was a tender popliteal cyst, and the lower leg was very swollen and erythematous.
As she told me the story I realised she was describing an acute attack of gout with a burst popliteal cyst, and I then found that her father had gout. Doppler studies after her discharge had ruled out a deep vein thrombosis. All the blood test results are compatible with acute gout, including the normal urate.
The pain and swelling of the knee rapidly resolved on treatment with diclofenac 50 mg four times daily (with a stomach protective), and the swelling and erythema of the lower leg gradually went away with the help of elevation and an elastic stocking. Strikingly, the skin over the front and sides of the knee peeled off massively during recovery, which of course is typical of gout and would not be expected after an infection.
Acute arthritis is quoted as a possible differential diagnosis in the article, and this case demonstrates that acute gout must certainly be considered.
Patient consent obtained.
Competing interests: No competing interests