Tuesday, May 5, 2009

Gout , Lyme or Both?

A middle aged man came into the office with acute pain, swelling, warmth and redness of a knee. He had no other symptoms to suggest chronic Lyme disease. Past experience, as well as all major texts indicated that that gout was the most likely culprit. The patient was treated with typical gout therapy: Indocin and Colchicine. Blood was sent to help sort out the usual suspects which may cause "acute mono-articular arthritis."

His uric acid acid level was quite high- 9.6- definitely compatible with the gout diagnosis. But the diagnosis was a bit messy. His serum Lyme WB by Labcorp showed IgG bands present at the 30 and 41 positions. And then, one week later the patient came back for a follow up visit. The gout therapy had not worked. The knee was a little better but now there was swelling of the great toe, the metatarsal phalangeal joint. This is the classic finding of gout. I aspirated the fluid. I only obtained a few CCs of blood tinged fluid. I sent the fluid for Lyme Western Blots. The results: 6 IgG bands present and 2 IgM bands present.

Now the therapy was converted to antibiotics rather than anti-inflammatory agents.
The patient could be unlucky enough to have both Lyme arthritis and gouty arthritis. The only way to confirm gout is to analyze the joint fluid for the presence of uric acid crystals. Unfortunately this test was not performed.

I could imagine that gout triggered Lyme or the other way around. This is the second case I have seen with the same presentation.

1 comment:

rsc said...

You can read more about gout here:
http://bit.ly/BOvAA