Question: Hi! My husband is 55 yo of Russian-Jewish descent. He is experiencing right ankle joint swelling, swelling of both hands, but worse in the right & lower back pain. His right ankle is visibly swollen & very painful for him to walk. He has a temp of 100.3.
Recent Hx: He was previously deficient in vit D but is currently taking 10,000 iu. He recently found out he has retinal damage due to lack of Vit A absorption due to a gastric bypass sg several years ago. When he has had these flares in the past (usually a couple of a year), his PCP has done blood work & ruled out gout and RA.
PMH: obesity, periods of ETOH dependence (red wine - I was wondering allergic??), ambien dependence, sleep apnea (good about using cpap at night).
He's fussing at me about not going to the doc again since he didn't find anything. I suggested a rheumatologist & let that doc r/o some type of auto-immune or inflammatory process. Obviously there is something wrong! In spite of his hx, he's been relatively healthy ie, good cholesterol, BP, no cardiac issues, etc

Thanks! XXXXXXX

Hi Dr. Prasad: Thanks for getting back to me. I will do my best to answer your questions:
1. When I probed more, he says he recalled that his feet "would kill him" even when he was a kid. However, the pain was never this intense until the last couple of years. He seems to get these bouts once or twice a year. He says the pain is typically of a gradual onset but that it elvolved into very painful the last few bouts. As I mentioned previously, the pain became so acute that he can barely walk. The pain abates some at rest when his legs are elevated but hurts worse during mobility, standing & ambulation. He takes vicodin which helps some but not totally. He took an OTC diutetic last night which he said helped some but the right ankle edema is still present. It didn't seem pitting but I'm not sure.
2. I am not clear as to how to desribe the pain: he says the bottom of his feet burn but that his ankle just "really hurt." He is not diabetic but I wondered about neuropathy?? His circulation is reportedly good based on some type of vascular tests - I think some ultrasound.
2. This last bout of acute painful swelling started about July 3 & is just starting to ease up some. He has been afebrile since I initially wrote you. When he's had these in the past, the most painful bouts abate but he ofen has residual swelling in his fingers. The right ankle & hand are the most edematous & but both ankles are tender. I don't see any redness.
3. I feel stupid for not mentioning this the other day, but he does have an infected anal fistula or fissure that has been painful & bleeding. He's proscrastinated but finally saw a proctologist who recommends surgery. I was worried that he was becoming septic or at least having a mass inflammatory response to a low grade infection. He has not been on ant ATB tx recently. He had this problem a few years ago & required surgery.
4. The only meds & supplements that he takes routinely:
- Testosterone cypionate Inj. 2000mg/10 mL; I give him 1 mL QOW. We wondered at one time if it was the suspension they mix the testosterone in that could be a problem.
- Generic ambien 5 to 10 mg QHS w/ 25 mg Benadryl for sleep. He does use his cpap at night. Sonetimes he drinks it w/ red wine. Yes, we know this is not a good idea!
- Vit D 3 soluble gel cap30,000 iu (He runs low)
- Vit A 8000 iu just started due to retinal damage (see above)
- Lutein & zeaxanthin (25mg & 5)
-Vit B 12 2500mcg
- ASA 81 mg QD
- Multivitamin
- Fiber capsules for constipation
It seems in the past, a doc suggested that it was a form of "pre-gout" or other type of gout but he did not show elevated uric acid in his blood work. He never took meds for gout.

What do you think about him seeing a rheumatologist? Any suggestions are appreciated!

Sincerely,
XXXXXXX

Thank you Dr. Prasad! I appreciate your input.

Sincerely,
XXXXXXX