A Patient With Hepatitis C Virus Infection and Inflammatory Polyarthritis

Abstract

A 65-year-old African American man with a 4-year history of nontophaceous, crystal-proven polyarticular gout presented to the emergency room with a painful left leg and knee swelling of 4 days' duration. A Doppler ultrasound revealed no deep vein thrombosis, and arthrocentesis of the left knee was performed (Table 1). Monosodium urate crystals were identified. Acute gouty arthritis was diagnosed and compliance with daily colchicine was recommended, along with leg elevation. Two days later, Streptococcus viridans (resistant to penicillin and ceftriaxone) and pan-sensitive Escherichia coli grew from the synovial fluid (SF). Attempts to contact the patient were unsuccessful.Twelve days later, the patient returned to the emergency room with worsening symptoms and an unchanged examination. A repeat ultrasound of the left lower extremity revealed a Baker's cyst, but no evidence of rupture. He was treated with ibuprofen and hydrocodone/acetaminophen, and was instructed to follow up with his primary care physician. No reference was made to the prior polymicrobial SF results.Four weeks later, without any resolution in his symptoms, the patient had his third emergency room visit within 6 weeks. Examination revealed a left knee effusion with limited and painful range of motion. He was admitted for further evaluation. Medical historyThe patient admitted to a consistent diet of 1 pint of alcohol every 3 days and frequent consumption of red meat and foods containing high fructose corn syrup. He was uncertain of his compliance with prescribed daily colchicine. A recent uric acid level was 9.6 mg/dl. He had a history of significant polysubstance abuse, including alcohol, heroine, crack cocaine, and marijuana, and a 48 pack-year history of cigarette smoking, all active in the past 4 years. He also had chronic obstructive pulmonary disease and a history of a positive tuberculin purified protein derivative (PPD) without documented treatment. Two years previously, he was treated for nonresectable, squamous cell carcinoma of the esophagus with radiotherapy and capecitabine, now in remission. He had hepatitis C virus (HCV) genotype 1a complicated by cirrhosis, portal hypertension, and ascites requiring frequent therapeutic paracenteses. He was also diagnosed with hepatocellular carcinoma 2 years prior to presentation, for which he received 3 treatments with transarterial chemoembolization (TACE) with epirubicin, the most recent 2 months prior to admission. MedicationsMedications included tramadol 50 mg 3 times daily, albuterol 90 g/ipratropium 18 g 2 puffs 3 times daily, omeprazole 20 mg twice daily, and amlodipine besylate 5 mg daily. Family and social historyHe had no family history of gout, had been unemployed for several years, and was intermittently homeless. Review of SystemsThe patient denied fevers or malaise, recent dental infections, rash, sinusitis, productive cough, dysuria, nausea, vomiting, or diarrhea. He had dyspnea on exertion and wheezing. He had no chest pain, palpitations, orthopnea, or paroxysmal nocturnal dyspne...