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Why does this woman have painful, swollen fingers?

This older lady with hypertension presented with acutely painful, swollen fingers on her right hand. Dr Mike Wyndham describes how he made the diagnosis

 

The patient

This 84-year-old lady suffered a stroke two years ago and is mostly confined to her home, where she lives on her own. Her name appeared in the triage list with the comment ‘swollen hand, too painful to use'. She developed this two days before calling. There was no history of injury and she was finding it hard to hold a kettle to make a cup of tea. Despite her symptoms, she did not feel unwell and her appetite was unimpaired.

Her past medical history included hypertension, which was usually well controlled, and she was taking bendroflumethiazide.

First instinct

The right hand looked very painful and was swollen in the carpal and proximal end of the metacarpals of the first four fingers. It was tender in those areas. She had a mild fever of 37.2°C and there was some dry skin in the affected areas. Was this gout or even septic arthritis?

Differential diagnosis

• OA first carpometacarpal joint

• Septic arthritis

• Pseudogout

• Gout

There was clear evidence of OA with joint deformities at the terminal interphalangeal joints. Not unsurprisingly, the first carpo-metacarpal joint had a squared appearance, consistent with the condition.

But although there was some mild discomfort on pressure of that joint, the second, third and fourth metacarpals with some of the carpal bones seemed much more painful.

Septic arthritis can develop from direct spread, via the bloodstream or from locally infected joints. The causes may be split between non-gonococcal and gonococcal but the latter seemed highly unlikely. There seemed no obvious direct cause, with the skin looking dry but intact. There were no locally affected joints.

Could it have spread haematogenously? She had not had any joint replacements and there were no obvious foci of infection.

But increasing age is associated with immunosuppression, and diabetes and rheumatoid arthritis are risk factors for septic arthritis, so sepsis couldn't easily be ruled out.

It is very hard to distinguish between gout and pseudogout, with the latter being caused by calcium pyrophosphate crystals. The knee and wrist are some of the joints commonly affected by the metabolic arthritides. The first metatarsophalangeal joint is, of course, the most common joint for gout.

Getting on the right track

OA was the least likely cause. Gout was a possibility as thiazide diuretics predispose to hyperuricaemia. Pseudogout could not be discounted. Sepsis was a possibility but she was not unwell.

I opted for gout or pseudogout and recommended she take her temperature three times a day and contact me if she felt unwell or the swelling deteriorated as it could be an infection. I also prescribed colchicine 500µg three times a day as I felt NSAIDs might have been too risky for her stomach. I organised for uric acid to be measured along with other bloods. Her uric acid was normal, making gout unlikely. Her temperature settled and her wrist swelling and pain disappeared. Pseudogout it was.

Dr Mike Wyndham is a GP in Edgware, north London

Painful, swollen fingers

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