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Why is this man's foot red and painful?

This patient hadn’t been in the surgery for years but a district nurse mentioned he’d been having problems walking. Dr Mike Wyndham describes how a checklist he learned as a houseman helped clinch the diagnosis

 

The patient

It was a phone call from one of the district nurses that alerted me to this 94-year-old patient. Actually, I hadn't seen him in about 10 years. It had been so long, I thought he had moved away from the practice area.

It transpired that the nurse was visiting one of his neighbours to do a dressing and she remarked that he had been struggling with walking over the past few days. The nurse had popped in to see him and wasn't happy with the state of his foot.

First instinct

Most of the toes on his right foot looked red and pretty uncomfortable. As I stood and gazed hoping for inspiration, I suddenly found myself going back to my old houseman checklist: congenital, inflammatory, infection, metabolic. It had got me out of jail several times in my career and I was hoping it would be my saviour again.

Differential diagnosis

• Multiple paronychiae (infection)

• Chilblains (inflammatory)

• Gout (metabolic)

Paronychiae often develop where nails have been picked at rather than cut. His nails certainly looked like they had been cut, although the second toenail looked a little peculiar, but he assured me that it had just grown that way. The infection usually affects the great toe and I can only remember seeing multiple paronychiae on one occasion in someone who constantly picked and bit at his toenails! So this diagnosis seemed rather unlikely.

Chilblains may affect the fingers and toes, with women more likely to be affected than men. Papules or nodules may develop, which occasionally can ulcerate. There may be pain or itching. He certainly complained of pain mostly affecting his second toe. The third and fifth toes looked red and there was a small white ulcer on the former. But even though the house was a little underheated, he assured me that the room he stayed in was always warm.

Gout, as even ordinary members of the public know, commonly affects the big toe. However, it can present elsewhere, particularly when there are tophi (deposits of urate crystals in soft tissues).

Getting on the right track

My eye was attracted to the second toe. The nail was so deformed, without any history of injury. There appeared to be a white cheesy material coming out of the nailbed. The third toe had a white ulcer. The diagnosis was clinched. This had to be tophaceous gout.

Dr Mike Wyndham is a GP in Edgware, north London

Red, painful foot

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