What is the treatment for a 60-year-old patient with red, warm, swollen toes, potentially with a history of gout?

Treatment of Red, Warm, Swollen Toes in a 60-Year-Old

Immediately immobilize the foot with knee-high offloading (total contact cast or removable walking boot) while pursuing urgent diagnostic workup, as this presentation in a patient with diabetes and neuropathy represents active Charcot neuro-osteoarthropathy until proven otherwise—a limb-threatening emergency that leads to fractures, deformity, ulceration, and amputation if left untreated. 1, 2

Immediate Assessment and Action

Critical First Steps

• Assess diabetes status and neuropathy immediately. Active Charcot neuro-osteoarthropathy (CNO) must be suspected in any patient with diabetes and neuropathy presenting with unilateral red, warm, swollen toes with intact skin. 1, 2

• Initiate knee-high immobilization/offloading promptly even before imaging confirmation, as delayed treatment risks permanent deformity and limb loss. 1, 2

• Measure skin temperature difference between feet using infrared thermometry at the same anatomic points bilaterally; a temperature difference ≥2°C strongly suggests active CNO. 1, 2

• Rule out infection urgently by looking for at least 2 signs of inflammation: erythema, warmth, tenderness, pain, induration, or purulent discharge. 1, 2

Differential Diagnosis Priority

The three most critical diagnoses to distinguish are:

1. Active Charcot neuro-osteoarthropathy (if diabetes with neuropathy present) 1, 2
2. Acute gout flare (especially first metatarsophalangeal joint involvement) 3, 4, 5
3. Diabetic foot infection/osteomyelitis (if ulceration or bone exposure present) 1, 2

Diagnostic Workup

Immediate Testing

• Obtain plain radiographs of the foot as first-line imaging to evaluate for fracture, bone destruction, dislocations, or chronic deformities. 1, 2

• Order MRI if plain radiographs are normal but clinical suspicion remains high for CNO or osteomyelitis, as MRI detects bone marrow edema before structural changes appear on X-ray. 1, 2, 6

• Perform arthrocentesis with synovial fluid analysis if gout is suspected, looking for negatively birefringent monosodium urate crystals under polarized light microscopy. 3, 4, 5, 7

• Probe any ulcers to bone with a sterile blunt metal probe; ability to probe to bone strongly suggests osteomyelitis. 1, 2

Key Clinical Findings

• Test for loss of protective sensation using Semmes-Weinstein monofilaments or 128-Hz tuning fork to confirm peripheral neuropathy. 2, 6

• Document glycemic control and review HbA1c, as poor glucose control increases risk of both CNO and infection. 1, 2

• Assess for "sausage toe" (red, swollen digit), which should arouse suspicion of osteomyelitis. 1

Treatment Based on Diagnosis

If Active Charcot Neuro-Osteoarthropathy Confirmed

• Apply total contact cast (TCC) or irremovable knee-high offloading device immediately and continue for 3-6 months until remission is achieved. 2, 6

• Monitor temperature differences weekly; remission is indicated when temperature difference normalizes to <2°C for several consecutive weeks. 1, 2, 6

• Provide customized therapeutic footwear with molded insoles after remission to prevent recurrence. 2, 6

• Classify patient as high-risk requiring multidisciplinary foot team review every 1-3 months after acute episode resolves. 2, 6

If Acute Gout Flare Confirmed

• Administer colchicine 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later for maximum dose of 1.8 mg over one hour. 8, 3, 4

• Alternatively, use NSAIDs as first-line treatment if no contraindications exist; the most important determinant of success is how soon therapy is initiated, not which NSAID is chosen. 3, 9, 5, 7

• Consider corticosteroids (oral, intravenous, or intra-articular) if NSAIDs and colchicine are contraindicated. 3, 9, 5

• Initiate urate-lowering therapy (allopurinol or febuxostat) if patient has 2 or more gout flares per year, tophi, or radiographic evidence of gouty arthropathy, with goal serum uric acid <6 mg/dL. 4, 5

If Diabetic Foot Infection/Osteomyelitis Confirmed

• Start empiric antibiotics targeting gram-positive cocci (Staphylococcus, Streptococcus) for mild infections. 2

• Initiate broad-spectrum IV antibiotics for moderate-to-severe infection and assess need for urgent surgical debridement. 1, 2, 6

• Obtain blood and wound cultures before starting antibiotics and reassess at 48-72 hours for clinical improvement. 1, 2

• Continue antibiotics for 4-6 weeks if osteomyelitis confirmed, with consideration for oral switch after initial parenteral therapy. 1

Critical Pitfalls to Avoid

• Never delay immobilization while waiting for imaging in diabetic patients with neuropathy and swollen, warm toes—untreated Charcot leads to irreversible complications. 1, 2

• Do not assume infection is absent just because the patient lacks pain, as sensory neuropathy may mask typical pain response. 1

• Avoid starting urate-lowering therapy during an acute gout flare without concurrent anti-inflammatory prophylaxis (colchicine, NSAIDs, or low-dose corticosteroids) for at least 3-6 months. 8, 3, 4

• Do not use colchicine at higher doses than recommended; doses exceeding 1.8 mg over one hour for acute gout treatment have not been found more effective and increase toxicity risk. 8

• Screen for HLA-B*58:01 allele before starting allopurinol in high-risk populations (Asian descent, chronic kidney disease), as this variant increases risk of severe cutaneous adverse reactions with odds ratio 80-580:1. 1, 4

Multidisciplinary Coordination

• Coordinate care with diabetic foot team including podiatry, infectious disease, vascular surgery, and orthopedics for high-risk patients with diabetes, prior ulcers, amputation history, or Charcot foot. 2

• Instruct patient to inspect feet daily using palpation or mirror if loss of protective sensation is present, and emphasize smoking cessation. 2