537 - Progressive dactylitis refractory to medication treatment in chronic gout

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

SL

Suriya Lisa, MS

Medical Student
Georgetown University School of Medicine
washington, District of Columbia, United States

Co-Author(s)

SN

Sargoon Nepaul, MD

Resident Physician/ Physical Medicine and Rehabiliation
MEDSTAR NATIONAL REHABILITATION HOSPITAL
Washington, District of Columbia, United States
RB

Robert d. Bunning, MD

rheumatologist MedStar National Rehabilitation Hospital
MedStar National Rehabilitation Hospital
Washington, District of Columbia, United States

Case Diagnosis: Progressive dactylitis refractory to medication treatment in the setting of chronic gout.

Case Description: A 77-year-old man from Burma with a history of gout presented with left index finger swelling with a limited range of motion presumed to have a gout flare. He was on 100mg of Allopurinol daily with his blood uric acid level ranging from 6-6.5 mg/dL. His physical exam was significant for a limited active range of motion in the left index finger with diffuse hyperpigmentation consistent with chronic inflammation. Differential diagnosis included cellulitis vs. Tuberculosis dactylitis given his country of origin. He completed a course of Cefdinir, with subsequent MRI and X-ray of the finger negative for infection. Tuberculosis dactylitis was ruled out given a negative gold-quantiferon test. His medications included a trial of colchicine, Medrol Dosepak, and 300mg Allopurinol daily with a blood uric acid level of 6.1. Dual-energy CT scan showed uric acid clusters in the index finger and gout dactylitis was confirmed.

Discussions: His pain and swelling improved after a few months of medication but he continued to have a limited range of motion of his left index finger. He ultimately required a prosthetic replacement of the Proximal Interphalangeal (PIP) joint of the finger. His range of motion returned to 74 degrees following surgery. His finger pain and swelling continued to be well controlled on the regimen of Allopurinol 300mg daily. To the best of our knowledge, this is the first reported case of gout dactylitis of the index finger that was initially refractory to medication management subsequently requiring a prosthesis of the PIP joint.

Conclusions: Gout dactylitis of the index finger is a rare sequelae of prolonged gout presenting with swelling of fingers with a limited range of motion and can present with symptoms initially refractory to medications.