Gout only pain "foot", you are too naive! This patient has hand pain, abdominal pain, skin pain...

Don't want to miss Jiemei's push? Poke the blue word "medical rheumatism and nephropathy channel" to pay attention to us, and click the "·" menu in the upper right corner, and select "set as star" to realize how "painful" it is! Editor's note: on April 20, the theme activity of "fighting gout, we are in action" jointly launched by "rheumatism and nephropathy channel of medical circles" and Clinical Immunology Department of Xijing Hospital of Air Force Military Medical University is still continuing. We will continue to release clinical experience sharing and expert opinions of Clinical Immunology doctors in Xijing Hospital, aiming at popularizing scientific knowledge, helping standardized diagnosis and treatment of gout Please pay attention! This issue is a typical gout case sorted out by Dr. Xu yuemeng, Clinical Immunology Department, Xijing Hospital, Air Force Military Medical University! We all know that gout attack is first of all foot pain (the first metatarsophalangeal joint of both feet is red, swollen and hot pain is common). However, this gout patient's life has three "pains" - foot pain, abdominal pain and skin pain. What's going on? Hu XX, a 55 year old male, suffered from foot pain in 1998. After drinking, he suffered from swelling and hot pain of the first metatarsophalangeal joint of the left foot, which could be relieved within 48-72 hours.after repeated attacks, usually 1-2 times / year.2008 gradually involved the right metatarsophalangeal joint, double ankle joint, palmar finger joint and proximal interphalangeal joint of the right foot; non steroidal anti-inflammatory drug analgesic treatment was not effective for 1-2 months.2015, joint swelling and pain aggravated, multiple subcutaneous nodules in limbs, and repeated skin ulceration of feet; blood uric acid of 700umol / l was checked to diagnose "gout", and irregular diagnosis and treatment were carried out.2 the second "pain" -- skin pain recurred in December 2017, left foot joint redness, swelling, heat pain with ulceration, and outflow of bean curd like substances; the local hospital received "hormone and allopurinol" treatment, and the symptoms were relieved.in January 2018, red and congestive rashes on the scalp, face, back and limbs gradually appeared, accompanied by cough and yellow phlegm, without fever.February 2018, multiple rashes on limbs and back with ulceration and scab, and obvious local pain.3 the third "pain" -- the history of abdominal pain was inquired, and the upper abdominal pain for 5 years was aggravated after eating, accompanied by acid regurgitation and heartburn, without hematemesis, hematochezia and melena, and relieved after taking NSAIDs.▎ auxiliary examination routine blood test: WBC 10.26 × 109 / L, neu% 0.849, HGB 85g / L; urine routine examination: protein qualitative 1 +; stool routine: occult blood suspicious positive; NT proBNP: 540.70pg/ml.biochemical renal function: UA 507umol / L, cre 251umol / L; blood lipid: TG 2.64mmol/l, LDL-C 5.71mmol/l; glycosylated hemoglobin: 7.1%.inflammatory ESR: 66mm / h; C-reactive protein: 17.50mg/dl; autoantibody series: Ana 1:100; anti CCP, anti MCV, anti aka were all negative.infection PCT: 0.294ng/ml; T-SPOT, G test, GM test were negative; sputum smear: a small amount of g-bacillus; sputum culture was normal; skin secretion smear: a small amount of G + cocci; skin secretion culture: Staphylococcus aureus, non MRSA.plain film showed asymmetric swelling of soft tissue around the joints of both wrists, hands and feet, with slightly increased density; some cystic and penetrating bone destruction was found under and at the edge of some joints.joint B ultrasound: typical "double track sign" dual source CT: hands and feet with multiple gout stones; Gastroscope: multiple gastric ulcer (stage A2); reflux esophagitis grade A (LA classification); atrophic gastritis with erosion.The clinical features of the first episode of "hyperuricemia" and "hyperuricemia" in middle-aged patients were analyzed After that, multiple rashes and skin ulceration occurred.pain causes: foot pain: Gout is not well controlled for a long time, causing joint erosion and destruction; abdominal pain: multiple gastric ulcer caused by long-term non steroidal anti-inflammatory drugs; skin pain: allopurinol allergy? Steven Johnson syndrome? Further examination of allopurinol gene locus: 133hla-b * 5801: positive; 51hla-b * 5801: positive; Methylprednisolone 80mg / D × 5D → methylprednisolone 40mg / D → obvious remission of systemic rash 5 final diagnosis and treatment diagnosis: gouty allergic dermatitis, renal insufficiency, skin infection, gastric ulcer anemia (moderate) type 2 diabetes, hyperlipidemia treatment: lifestyle education, methylprednisolone 8mg / D, febuxostat 40mg / D autumn Conclusion: after the symptomatic and supportive treatment with Narcissus 0.5mg bid, the swelling and pain of joints are obviously alleviated, and arthroscopic resection of gout nodules is carried out. We should strengthen the follow-up and health education for gout patients, and inform them of the necessity of long-term treatment and the possible risks caused by non-standard treatment. During the treatment, we should pay close attention to the side effects of drugs. Professor Wu Zhenbiaocommented on gout as a chronic disease with a higher incidence rate, a greater and greater risk of poor compliance in recent years. this case is a typical epitome of the current diagnosis and treatment of gout patients in China. the patient had recurrent joint swelling and pain, gradually appeared nodules, deformities, ulceration, and significantly increased uric acid. For 17 years, there was no regular treatment and intervention. it is suggested that once the typical sudden joint swelling and pain, dysfunction, especially the first metatarsal joint, has clear incentives, it is necessary to be highly vigilant against gout. Patients should go to the rheumatology department in time, and the doctors should carry out relevant examination for diagnosis of gout, make early diagnosis, early treatment and long-term management, so as to improve the prognosis. imaging examination is very helpful for the diagnosis and evaluation of gout. Dual source CT, ultrasound and X-ray of the patient showed typical gout changes. Clinicians should reasonably use these sensitive and special imaging methods to diagnose and manage gout. the treatment of reducing uric acid is the key to the long-term management of gout. Only when the long-term uric acid reaches the standard can we reduce the attack and control the disease. although allopurinol is the first choice of antiuricemic drugs recommended by international guidelines, some patients in Asian population will have severe allergic reactions, especially those with hla-b5801 positive. Once they appear, they are life-threatening and need early diagnosis and treatment. After taking allopurinol, the patient has severe skin reactions, pain and ulceration. The doctor has timely diagnosis, proper treatment and survived the crisis It is suggested that before using allopurinol, Chinese patients should carefully check whether there is any risk, and check hla-b5801 as much as possible. patients with gout often take a variety of non steroidal anti-inflammatory drugs on their own, so they have high risk of gastrointestinal injury and are prone to gastrointestinal bleeding. The patient has abdominal pain and positive fecal occult blood. Therefore, timely detection and diagnosis of peptic ulcer can avoid further injury. this case is typical and representative, which shows the classic course of the history evolution of gout patients. The diagnosis and treatment process shows the doctors' understanding and treatment level of gout, and indicates the importance of early diagnosis, long-term management and standard treatment of gout. patients have suffered from peptic ulcer bleeding, and glucocorticoids have potential risks, so long-term high-dose use should be avoided. Prof. Wu zhenbiao, chief physician, professor and doctoral supervisor of Clinical Immunology Department of Xijing Hospital, member of rheumatic immunology branch of Chinese Medical Association, standing member of rheumatic immunology branch of Chinese Medical Association, deputy leader of vasculitis group of rheumatic immunology branch of Chinese Medical Doctor Association Member of the Standing Committee, vice chairman of the vasculitis professional group, rheumatology and Immunology branch, Cross Strait Exchange Association, vice chairman, rheumatology branch, Shaanxi Medical Association