Painful lower extremities
By Tedler D. Depaynos, MD
The 46 years old male patient had been suffering from pain in both lower extremities. He described it to be emanating from his muscles so that his relatives had been massaging him at home but with little relief. After quite some time due to the worsening pain, he was not able to even stand up so that he was confined in bed. He was brought to a provincial hospital but when he was able to get a slight relief, he insisted that he had to be discharged because of his “mining” responsibilities. After a month or two he was again confined in bed because of severe pain. He was forced to be admitted in a regional hospital but again because he needs to supervise his “fruitful mining adventures”, he insisted to be discharged against medical advice.
He had been suffering for nearly a year already and using a wheel chair. His legs had become thinner or atrophied because of non-use. His “strong pain killers” were becoming useless. He apparently was resigned to his fate but because of a painful non-healing wound on his right foot he was forced to seek admission again in another hospital.
The wound was actually a ruptured tophi which is a tumor made up of uric acid. He had also a fixed hard “mass” at his right hip which was diagnosed by his attending MDs as another tophi. He was then diagnosed with uncontrolled gouty arthritis confirmed by a very high serum uric acid.
Tophi are masses due to accumulation of uric acid. They are usually found in the subcutaneous tissues as nodules but may also found inside the joints. Those found in the subcutaneous tissues may be excised completely but those inside the joints cannot be excised. With time and neglect, they may rupture and ooze continuously and healing maybe difficult. Secondary infection usually becomes an eventuality.
Accumulation of excess uric acid may also occur in the kidneys and the gallbladder and become “stones”.
The patient then confessed that he was diagnosed to be suffering from gouty arthritis in his previous admissions. He was given medicines for his gout but after taking them at home for a month or so they seem not effective. Hence, he shifted to stronger “herbal medicines” suggested by their neighbors and they made him “comfortable”. When he was brought to the other hospital he was hoping that more effective anti-gout medications would be prescribed but to his frustration, same medications were given so he again insisted to be brought home.
Standard treatment for high uric acid is “allopurinol” which controls the formation of uric acid. Newer medications are now in the market which prevents its formation and even medications that hasten it excretion thru the kidneys.
The formation of uric acid is a continuous metabolic affair so that anti-uric medications do not work overnight. It would take some time to feel the reduction and it has to be taken sometimes for life. Probably, this was not explained to the patient. He thought that the drugs prescribed were miraculous.
As a rule, the anti-uric acid medications are only given when the pain is already controlled because if not, they may make the pain more severe. Various pain killers are also available for gout and the classical medication is the so called “colchicine”. In severe cases, “steroids” are prescribed but this should be under strict MD supervision because of the possibility of complications.
Alcoholized water (alcoholic beverages) may inhibit the excretion of uric acid thru the kidneys and may even precipitate the painful attack. Like this patient, many other hard headed patients insist that it is effective as a pain reliever especially so when it makes them sleep. Besides, the supply is unlimited and may be cheap.
The patient admitted that they butchered animals to give thanks whenever they made a “hit” in their mining adventures and his favorites were the “chicharon bulaklak” and “pnapaitan” which are very high in uric acid. In our old textbooks, legumes, avocado, entrails, sardines and even tuna fish should be avoided. Intake of adequate plain water is also advised to help the kidneys do their work.
The patient underwent debridement of his leg wound and was advised with strong words to take his anti-gout medications religiously or else he would be confined permanently in his wheel chair. He was also requested to bring samples of his “nava” or gold ore for his young MDs to appreciate on his return visit. They had never seen or touched a sample.**