1. Heel pain in an adult male Hatem H Eleishi, MD Lecturer of Rheumatology, Cairo University June 2004

2. A 54-year old barber 3m: Bilateral heel pain Worse with prolonged standing and for a few seconds when he first steps on the floor after waking up in the morning. Staying at home on Mondays improved his symptoms. He had no other complaints.

3. He had been receiving oral hypoglycemics for diabetes and was advised to restrict salt in his diet to control a mild elevation of his blood pressure.

4. Examination: Apart from a BP of 140/85 and mild tenderness of his heels, examination was unrevealing. Laboratory investigations: ESR 5; CBC: normal Kidney, liver, electrolytes: normal PPBS 157 SUA 7.9 (2-6.5mg/dL) Cholesterol 265 (up to 240)

5. This patient’s heel pain is probably caused by_____ and should be managed with_______: 1.Gout / allopurinol 2.Gout / colchicine 3.His job / reassurance and instructions 4.Reiter’s disease / NSAIDs & MTX 5.Osteoarthritis / analgesics

6. A 24 urinary excretion of uric acid done for this patient was 700mg (normal: 600-800mg)

7. What would you do for this patient’s hyperuricemia: 1.Treat with allopurinol 2.Treat with a uricosuric 3.Treat with low dose corticosteroids 4.Do nothing

8. Asymptomatic moderate hyperuricemia has never been shown to be bad Hyperuricemia and gout Only 1/3 develop gout Gout is treatable and is much more benign that its treatment

9. Hyperuricemia and heart disease Hyperuricemia Hypertension Hyperglycemia Hyperlipidemia Asymptomatic moderate hyperuricemia has never been shown to be bad Never shown to be directly implicated in CHD risk However

10. Hyperuricemia and renal disease Apart from acute uric acid nephropathy, No evidence of renal toxicity Asymptomatic moderate hyperuricemia has never been shown to be bad

11. For many years, investigators wondered why humans were not gifted with ‘uricase’ like other animals were Hyperuricemia in humans versus other animals

12. Animals have uricase Humans don’t have uricase Rather, they have less efficient methods of getting rid of uric acid and so are more likely to get hyperuricemia So they don’t get hyperuricemia

13. In fact, Moderate asymptomatic hyperuricemia has recently been shown to be good Hyperuricemia and the heart A major plasma antioxidant in patients with Hypertension Hyperglycemia Hyperlipidemia

14. Hyperuricemia and the kidney Prevents reperfusion injury after exercise

15. So it seems that Some hyperuricemia is good Just as Some fever in acute infections is good Just as Some diarrhea in infect. gastroenteritis is good Just as Some elevation in SAA in inflammation is good

16. So when you see a patient with asymptomatic hyperuricemia and manage them Hypertension Hyperglycemia Hyperlipidemia and leave the hyperuricemia alone It is good

17. That’s it…