Gout and Secondary Cellulitis

A 61 year old man came in this morning and he specifically requested to see me. I was quite touched though this was not the first time that patients had made that kind of special request. This man had a more than 28years history of hypertension, heart disease and gout. He was actually being followed up by a Cardiology clinic at the General Hospital but had been coming to the clinic and saw various doctors for simple aches and pain.

I greeted him as he was hobbling into my clinic. He had a swelling on his right foot and according to him it had been there for the last four to five days following his attendance of the Sultan of Brunei's birthday a week before. He had felt some pain in his right foot and had attributed it to the gout that he had been suffering from. It seemed that the attack came on just when he had to go to the palace where he had to wear shoes. So as the skin area above his first metatarsal began to swell, he had forced his shoes over it and bit his lips and took a painkiller.

He went to a doctor who prescribed him with indomethacine, a non-steroidal anti-inflammatory drug (NSAID) and told him to rest at home but the swelling  had become bigger, extending up to to his right ankle,  the tenderness had also worsened and he was beginning to feel feverish.

He looked well despite his temperature of 38deg C (normal 36.8). I took one look at his right foot and noted that it was no longer a simple gout but has become a rapidly spreading skin infection (cellulitis) as his right groin nodes were palpable I could see that this man needed a rapid antibiotic therapy which could only be given through an intra-venous line so I quickly referred him to the Emergency Department of the GH for admission possibly for 24 hours and following which an oral antibiotic would follow and he could return home to rest. Cellulitis can be dangerous as it could spread over the whole body and causing  fatal septicaemia.

Foot cellulitis- red,swollen,warm and tender

What could have happened was his affected foot, upon being squeezed into his shoe,  had  the swollen area  scratched and thus provided an entry for the surface germs causing rapidly developing cellulitis.

I  took an x-ray of the foot and tested his random blood sugar (RBS) just  to exclude any trauma and  the possibility of diabetes before sending him off to the hospital.

Bone spurs on Ist big toe joint -site of constant gouty attacks

It is sometimes difficult at the primary care level to distinguish between a gouty attack and a cellulitis. My usual question is whether the person is feeling off-colour and that the swelling is extending Unless you ask the patient you are going to just give him a painkiller and ask him to go home only to suffer from a worst outcome.

He gave me permission to to take the photographs of his affected foot and that of his x-ray for my record purposes.