It’s Monday – that means another fascinating medical case for you to solve! This one was suggested by an M.D. To Be reader. Can you guess it?
A 54 year old man goes to his primary care physician because his toe is swollen and painful. He says the pain is excruciating, though he does not recall any trauma to the foot. The patient reports the toe has been giving him problems for a “long time,” with several past episodes of swelling and pain, but he has been reluctant to see a doctor. He has tried taking over the counter pain medication at home, which help minimally. The patient’s other medical problems include obesity (Body Mass Index is 33) and alcohol abuse, binge drinking up to 12 beers on weekends. He takes no medications.
The patient’s vital signs are normal. Generally, he appears to be uncomfortable and in pain. His left big toe joint is markedly swollen, deformed, and red (shown below). The toe is difficult to examine, since the patient will not permit the doctor to touch it or move it due to severe pain. The rest of the physical exam shows obesity but is otherwise normal. After some strong pain relievers, the physician is able to sample some of the fluid from the patient’s joint with a needle (shown under the microscope). She sends him for an x-ray of the foot (shown below).
What is the most likely diagnosis?