Dx: gout, but not really

In My Humble Opinion
1

Actual medical condition, but advice is for entertainment purposes only; you are not my doctor, or even a doctor.

I’ve had around 15 gout attacks in the last 12 years (more if you count onsets that never developed). I’m very familiar with them, their profile and their pain. Every attack has followed the same profile. Standard treatments (colchicine, colcrys) work very well and very quickly.

But this latest attack is different, and ongoing. Either it is a kind of gout I’ve never experienced (and I’ve never heard of different “kinds”), or it isn’t gout, or it is gout with a twist of Lyme, or something.

I’d like to be concise, but perhaps there is something in the history that is important, so I’ll include more detail than usual.

Pre-attack: about 3 weeks ago I awoke to a dull ache in my right foot, around the big toe-second toe area, in the ball of the foot. No sharp pain that I associate with gout, but tender, caused some limping. Over the next 3 days the pain moved across the foot day-by-day, ending up near the little toe. After 4 days, the pain completely disappeared - I was back to 100%. This episode may or may not be relevant, I don’t know.

After 2 days of no problems, the pain returned to the big toe side of the ball of the foot. Started the same - dull ache, tender, but no shooting pain. After a day or so, the shooting pains start, ones that I do associate with gout. It got progressively worse, causing me to visit the ER. The ER PA says “gout”, which I understand, but I explain the pain profile isn’t what I normally have with gout. They do a precautionary X-ray, give Colcrys, pain med, and precautionary antibiotic, and send me home. I return home and take two more doses of Colcrys.

Three days later and the symptoms have not lessened at all; I’m on pain pills almost all the time. This is not a normal gout attack for me.

I visit my PCP; he says “gout”. I explain that I understand why he’s saying that, but it doesn’t feel like my normal gout attack, based on the pain profile, duration, and non-responsiveness to Colcrys. He’s 100% sure it’s gout; gives me a steroid shot and high-power anti-inflammatory. He guarantees I’ll feel better in the afternoon.

And I do feel better, much better. By the evening I’m walking close to normal. Some tenderness and soreness remains, but I’m now functional.

I continue taking the anti-inflammatory for a week, which is about 3 days longer than the PCP anticipated I’d need them. I stop taking them because it seems I’ve plateaued: the pain is tolerable, but still there.

I’ve been off the anti-inflammatory for 5 days, and status quo: I have a dull ache all the time in the ball of my foot, with some redness. I can flex my toe without sharp pain, but the soreness/tenderness remains, getting worse at times to the point that I start limping again.

Pretty much the whole profile of this attack is unlike my typical gout attack, except for the moments of sharp shooting pain. Thankfully, those moments haven’t occurred much, which again indicates to me this is either not gout, or it is some other type of arthritis, perhaps.

tl;dr: some temporary (3-4 days) gout symptoms of unbearable sharp pain, but surrounded by weeks of dull aches that are not gout-like. Diagnosis?

The main purpose of this is that pain is again getting worse (but without the sharpness typical of gout), and I need to discuss some alternatives with my PCP, but I want some alternative diagnoses to present.

2

That does sound strange. My gout attacks are pretty localized and follow a steady pattern.

Have you been put on any blood pressure medicines lately? I was prescribed a diuretic and that was kicking off gout attacks about once a month.

This might be the time for a second or third opinion.

3

I’ve been stable on hypertension meds for years; nothing added in the past couple of years, although I did drop the beta blocker about 3 months ago.

Many years ago I had an experience with a blood clot, so that was always in the back of my mind, even though clots in the foot are pretty rare. Both docs dismissed the possibility, and since it’s been ~3 weeks, that probably isn’t it anyway.

4

Couldn’t they test your Uric Acid levels to confirm a diagnosis of gout? I’ve been dx’ed with gout before, but I don’t believe it was each time. Especially since the next time I had a different experience . . .

I’ve learned that I’m prone to Cellulitis infections - that would cause spreading pain without the stabbing you’re familiar with - however, I haven’t heard of it spreading, retreating and then spreading again unless an antibiotic was getting it under control and then it wasn’t responding to the meds. It would have the tenderness and spreading redness - but it would continue to spread in my experience. I have had to go from oral meds to IV antibiotics and to a pump to get it under control.

I thought of it only because it generally affects my feet and lower legs.

5

Maybe ask for a referral to a podiatrist?

6

Heckity, I’m guessing Cellulitis is what the PA at the ER might have been thinking as a backup diagnosis (after I kept saying it wasn’t my usual gout pain profile), and why she prescribed me the 10-day course of antibiotic. A lot of the symptoms sound similar, but there is no wound.

On the uric acid testing: in a past straight-up gout episode a couple of years ago I mentioned that to a doctor (a PA at my PCP office), and she said that often the uric acid level may well have reduced, even though the inflammation was current, sort of a hit-and-run, and that testing at the onset - if a low level is shown - may not be worth a lot. I may bring it up again, though.

If it helps: the first onset of the original pain was after spending a couple of days at a desk with less movement than usual, and in a position where circulation to my legs was partially restricted (leaning back, edge of chair just above the knees).

Inna Minnit, I’ll probably give my PCP one more shot - we have a good rapport, at least. If I don’t get anywhere productive, I’ll see a specialist. But before I see him again I wanted to see if there were some common alternative diagnoses that made sense to mention.

7

FWIW Raza, I’ve never had a discernable wound with an infection either. I have been told that you could have a small paper cut on a finger and the infection manifests in your feet/legs, or anywhere else. However I’ve never been able to find any wound, cut, bug bite or otherwise.

Because I’m sadly experienced, I have a standing order of antibiotics (oral) at the drug store. I start a round as soon as I identify an infection is starting. I draw a circle around the red area in pen and watch. If the redness doesn’t start to recede, or in fact continues to grow after three days on the oral meds I go to emerg and get an IV started.

My experience is that I always feel as if I’ve been kicked in the area (legs) or had something heavy dropped on my foot and then the real pain starts. It is quite different from gout pain that is more sharp pain, rather than a gnawing “in the bone” pain of cellulitis.

I hope you get answers and suitable treatment for what ails you - and of course that you feel better soon.

8

Just to wrap a bow around this: I visited an orthopedic doctor. They took more X-rays, finding everything fine, but confirming my pain, the swelling, and most-telling, the redness. She trusted my judgement that it wasn’t gout (or wasn’t only gout, those gout-like symptoms having disappeared, but the soreness remaining).

She said that surprisingly mine was the second case that day that was similar. I explained that I had been on a 10-day course of Keflex. She said there is one antibiotic that she never prescribes EXCEPT for these cases (unknown foot soreness not due to structural issues). She related that she had a similar case where the only thing that fixed it was this other antibiotic, and it took two courses: bactrim, I believe.

About the 7th day of taking bactrim I could feel that it really was getting “cured”; my benchmark of wellness - being able to sleep in various positions without my foot/toe being tender - was reached.

That was about a week ago, and I’m still pain-free. Whether it was an infection cured by the antibiotic, or something else that coincidentally went away, we’ll probably never know.

9

I’ve had gout attacks, but have also had something that is a lot like what you’re describing. I get it when I’ve been at the desk for long stretches, and believe it comes from sitting with my toes curled or bent for ages. Sometimes it’s a dull ache, other times feels like the onset of gout, but doesn’t become a full blown attack or get very red. Set the timer and flex those toes!

10

YES, exactly! One correlation I noticed, one that I mentioned to every doctor but which was discounted, was this always happened after a Sunday of sitting at my home computer, being quite sedate AND sitting in a chair in a way that restricted lower-leg blood flow.

I don’t know how they’re connected, or if it is just a coincidence, but I’ve had two recent incidents where there was a direct correlation.

11

Not diabetic by any chance, are you Raza?

12

A1C runs around 6.1. The orthopedic doc did mention that diabetics sometimes need two courses of antibiotics to fight lower-extremity infections.

13

I discovered that when I’m concentrating on the computer, I tend to sit with my feet not flat on the floor but heels up a little, thus bending the toes and holding them there for a while. The pain doesn’t come on until much later, so figuring out the connection wasn’t as simple as it sounds it should be.:smack:

14

I just read tonight (Dr. Google told me) that certain blood pressure medications can cause foot pain similar to gout. I think you’re probably on the right track for yourself, but I found that very interesting.

15

Heckity, if you could give me some specifics to search for, I’ll check into it. I’ve been on the same meds for years (actually, fewer nowadays, so progress!), but that doesn’t mean there couldn’t be symptoms just now showing up.