DOUGLAS D. Dykman, MD, Senior Assistant Resident in Medicine, the Jewish Hospital of St Louis: A 76-year-old woman presented with fever and mental status changes. Her medical history was notable for hypertension, diabetes, atherosclerotic peripheral vascular disease, and polymyalgia rheumatica. She had been admitted to the Jewish Hospital three weeks previously for incision and drainage of a sterile hematoma of the right foot. At that time, a uric acid level of 870 μmol/L (14.6 mg/dL) was noted. There was no prior history of gout or renal stones; her serum creatinine level was 150 μmol/L (1.7 mg/dL). Allopurinol therapy was initiated at the time of discharge at a dose of 300 mg/d.
She did well until two days prior to admission, when she developed weakness, nausea, vomiting, and low-back pain. Her family also noted a progressively increasing lethargy and confusion and brought her to the emergency room.
Her medical history was
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