Acute Painful Great Toe in Elderly Patient Post-Hospitalization
Differential Diagnosis
- Cellulitis or soft tissue infection typically presents more diffusely than monoarticular involvement, and may be caused by less common organisms like Proteus mirabilis in elderly patients with vascular compromise 1, 2
- Charcot neuro-osteoarthropathy should be considered in diabetic patients, presenting with unilateral foot redness, warmth, and swelling, and may have minimal pain due to neuropathy, requiring immediate immobilization while awaiting imaging 3
Immediate Diagnostic Workup
- The Infectious Diseases Society of America recommends sending synovial fluid for cell count with differential, Gram stain and culture, and polarized light microscopy for monosodium urate crystals 1, 2
- Complete blood count and inflammatory markers such as ESR and CRP should be obtained, as they may be elevated in both gout and infection 4
- Blood cultures should be taken if the patient is systemically ill or has a fever 5
Imaging
- Plain radiographs of the foot should be obtained immediately to look for bone destruction, gas in soft tissues, or chronic tophaceous changes 3, 6, 4
- MRI may be necessary if the diagnosis is unclear, as it is the most accurate imaging modality for detecting osteomyelitis and deep soft tissue infection 6, 4
Treatment Algorithm
- The American College of Rheumatology recommends immediate empiric antibiotics if septic arthritis is confirmed or cannot be excluded, with vancomycin and ceftriaxone or cefepime being suitable options 1, 2, 7
- Urgent orthopedic consultation is recommended for possible surgical drainage if septic arthritis is confirmed 1, 2
- If gout is confirmed, colchicine is the preferred first-line treatment option, but NSAIDs or corticosteroids may be used if colchicine is contraindicated 1, 2
Supportive Care
- The European Respiratory Society recommends rest, elevation, and ice application for comfort, as well as adequate hydration and analgesia with acetaminophen 7