ABSTRACT
Gout is a chronic disease characterized by recurrent attacks on joints from monosodium urate crystal deposition causing inflammation and severe pain. Patients at increased risk of developing gout include those with obesity, high consumption of alcohol or high-purine foods, genetic causes, and medication side effects. Typically, there are three stages of disease progression: acute, inter-critical, and chronic. Monoarticular joint disease is common however polyarticular gouty arthritis can result after years of acute flares. The chronic nature of the disease forms tophi, which are generally painless solid urate crystal collections. We present an unusual case of a 33-year-old male whose initial presentation was severe tophaceous gout affecting multiple joints, including bilateral elbows, knees, as well as hand and foot joints. His presentation was unique in that the tophi were not firm as expected, but were erythematous, tender, and fluctuant resembling an abscess. Laboratory and imaging studies confirmed the diagnosis of tophaceous gout and the patient's symptoms improved after starting systemic steroid therapy and colchicine. A multidisciplinary effort involving the medicine team and infectious disease, podiatry, and rheumatology consultants was essential in reaching the diagnosis. This case highlights the importance of keeping a broad differential diagnosis in a patient with polyarticular lesions and considering gout even with an atypical presentation such as in our patient.
ABSTRACT
UNLABELLED:  Introduction. Treating difficult-to-heal wounds with complexities, including those with exposed tendon/bone or infection, is a challenge that regularly confronts practitioners in a variety of clinical environments. The purpose of this study was to review the effectiveness of an acellular fetal bovine dermal repair scaffold (PriMatrix Dermal Repair Scaffold, TEI Biosciences, Inc, Boston, MA) used to treat complex difficult-to-heal wounds presenting in the authors' practice. METHODS: A retrospective chart review was conducted of a single practice with multiple practicing physicians between 2008 and 2010. Over this time period, 70 patients with 83 wounds were treated with the acellular fetal bovine dermis following surgical debridement of the wound. Forty-nine patients (58 wounds) met established inclusion/exclusioncriteria and were critically evaluated. RESULTS: Wounds treated with the acellular fetal bovine dermis included chronic diabetic wounds, venous wounds, and pressure ulcers, as well as wounds caused by trauma and surgery. Additionally, the patients treated had comorbidities commonly associated with recalcitrant wounds. Of the wounds evaluated in this study, 75.9% successfully healed; 63.8% reepithelialized, and 12.1% were closed with a skin graft subsequent to treatment. Notably, the majority (58.6%) of the wounds reepithelialized by 12 weeks following a single application of the dermal repair scaffold. In the subset of challenging wounds with exposed tendon/bone, 80.8% of the wounds were treated successfully (61.5% reepithelialized, and 19.3% were skin grafted), indicating the successful regeneration and reepithelialization of new vascularized tissue by fetal dermal collagen in relatively avascular wound defects. CONCLUSION: The acellular fetal bovine dermal repair scaffold can be used as part of an effective treatment regimen to heal complex wounds with exposed tendon/bone caused by varying etiologies. The product actively participates in the generation of a new, vascularized tissue capable of reepithelializing, or successfully supporting, a split-thickness skin graft in defects where initial grafting or living skin substitutes are not viable options. .
