Gout and Shoulder Pain

Today's case involved a 33-year-old man with end-stage renal disease on hemodialysis due apparently to hypertensive nephrosclerosis.  The man had had left shoulder pain for around one year, and was given a presumptive diagnosis of pseudogout and treated as such without resolution.  On admission his physical examination did not strongly suggest an articular or periarticular process.  X-ray and CT imaging showed a large lytic lesion in the humerus, which is being further characterized by MRI with a view toward biopsy. The current diagnosis remains unclear, but we look forward to hearing more about this in the future!

We discussed multiple medical expert and non-medical expert topics, learning points include:

-We discussed that the differential diagnosis for shoulder pain includes articular processes (gout, pseudogout, hemarthrosis, septic arthritis, etc.) as well as non-articular processes (referred pain from MI or diaphragmatic irritation, a bony lesion, a muscular problem, venous thrombosis, etc.)

-A first diagnosis of gout/pseudogout should probably involve a diagnostic arthrocentesis of the affected joint when the diagnosis is not clear.

- We discussed gout, and the approach to treatment which includes NSAIDS (when there isn’t a contraindication, typically naproxen 250-500mg BID with some gastroprotection) followed by colchicine therapy for 6 weeks.  Do not start allopurinol or other urate-lowering agents during an acute flare of gout.

Further Reading:

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• New perspectives on the management of gout, a common primary care disorder. [Postgrad Med. 2012]
• Gout. [N Engl J Med. 2011]

Nuki, G. (2006). Treatment of crystal arthropathy—history and advances. Rheumatic Disease Clinics of North America, 32(2), 333-357.