Consider a recent case that I saw. The diagnosis was unquestionably gout. A joint tap—deftly accomplished by a rheumatology fellow—produced several drops of cloudy albeit blood-tinged fluid. Using the marvelous optics of the polarizing microscope, the diagnosis was a slam dunk as yellow crystals glowed luminously on the slide. While the fluid was sent for gram stain and culture, the evidence was sufficient to start treatment. Treating gout should be simple except, for this patient and numerous others we see, it was limited by far more Scylla and Charybdis channels than I like to navigate.
The patient was 72 years old, looked 100, and was breathing oxygen frantically through a nasal cannula. He had heart failure and an ejection fraction of 20. His creatinine was 2.5; his blood urea nitrogen was 60 and rising as intermittent squirts of Lasix squeezed fluid from his tissues. As if that was not bad enough, he had a fever and an infiltrate on chest X-ray that could have been pneumonia, atelectasis, or pulmonary congestion; maybe two out of three or—if the patient was especially unlucky—all three together in a perverse trifecta of pulmonary misfortune. Oh, did I forget to mention that he was on coumadin because he recently had a pulmonary embolus that almost killed him? In the midst of all this trouble, the poor man now had gout that was scalding the skin off a knee that shined bright red.
In the old days, gout was a simple problem and colchicine was the morning-after pill for an evening of debauchery. Now gout is a therapeutic dilemma, with a chessboard of decision-making filled with seeming checks and checkmates as solutions are conjured. NSAIDs? No way. The creatinine and heart failure make them a bad choice. Systemic corticosteroids? Possible, but the infectious disease consultant tending to the pneumonia is worried about immunosuppression. Intraarticular steroids? With the INR near 3, an errant needlestick could flood the joint with blood.
What Would You Do?
I won’t tell you what I recommended. Send your suggestion to me at [email protected]—I’m curious what others would decide. The point is, as people have grown older and sicker, medical decision-making has escalated in complexity.
Dr. Jim Fries has written presciently and eloquently about the compression of morbidity. His hypothesis is, as medical care has improved and life expectancy has increased, the time a person suffers from disability diminishes and concentrates at the very end of life. The good part is that many people live longer, happier, and healthier lives, with the price of longevity paid mostly at life’s denouement.
