Acute Arthritis of the Fingers in an Elderly Woman

An 88-year-old woman was referred for acute arthritis of the fingers. Twelve days previously, she had experienced acute pain with swelling of the right 4th proximal interphalangeal joint (PIP). Several days later, she developed a lowgrade fever and pain of the 3rd distal interphalangeal joint (DIP). She had experienced a similar attack six months earlier that had resolved within a week. Her medical history included chronic heart failure due to aortic valve stenosis for 20 years, and chronic kidney disease. She was taking aspirin, candesartan, and furosemide. A physical examination showed tenderness, swelling and redness of the 3rd DIP and the 4th PIP joints, both of which included internal deposits and were superimposed on osteoarthritis (Picture 1). Hand radiography showed typical nodal osteoarthritis of DIP and PIP (Heberden’s and Bouchard’s nodes, respectively) associated with widening of the soft tissue shadows (Picture 2). Joint puncture revealed needle crystals (Picture 3). Gouty arthritis superimposed on nodal osteoarthritis is rare, and twothirds of cases are in women. Most have predisposing factors of hyperuricemia, including hypertension, renal impairment, and long-term diuretic use (1), as seen in our patient.