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Hand pain

A 75-year-old man sought care for pain in his right hand, which had been bothering him for 3 weeks. Two months earlier, the patient had begun taking hydrochlorothiazide—in addition to the ACE inhibitor he was already on—to better control his blood pressure. Upon further questioning, the patient admitted to having pain at the base of his left big toe 30 years earlier. The patient said he drank 2 to 3 beers a day and that he loved to eat hamburgers.

What's your diagnosis?


The family physician (FP) recognized that this patient was having an attack of gout, which was most likely exacerbated by the new prescription for hydrochlorothiazide. The patient’s serum uric acid level was highly elevated (12.1 mg/dL). No joint aspiration was attempted because the diagnosis was well supported by the history, physical exam, and elevated serum uric acid level.

Crystalline arthritis is caused by the deposition of uric acid crystals (gout) or calcium pyrophosphate dihydrate crystals (calcium pyrophosphate dihydrate crystal deposition disease) resulting in episodic flares with periods of remission.

Treatment for acute cases of gout include nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicine. The treatment of chronic gout includes modifications to diet and existing medications and the lowering of urate levels. Patients are encouraged to:

  • reduce the intake of purine-rich foods (eg, organ meats, red meats, and seafood)
  • increase fluid intake to 2000 mL/d
  • lower alcohol intake
  • consume dairy products as these may be protective against gout
  • change medications. Specifically, discontinue aspirin and consider stopping a thiazide diuretic. Lower urate levels with xanthine oxidase inhibitors (eg, allopurinol), uricosuric agents (eg, probenecid), or uricase agents (eg, pegloticase).

In this case, the FP replaced the thiazide diuretic with a calcium channel blocker. The patient was treated with colchicine to stop the acute inflammation. He was also told to drink less alcohol (or abstain from it) and to avoid red meat in his diet.

Photo courtesy of Robin Treadwell, MD and text courtesy of Richard P. Usatine, MD. This case was adapted from: Chumley H, Usatine R. Arthritis overview. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:562-568.

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