Dyspnoe, cough and fever in 80-year old patient with chronic heart failure

The prevalence of heart failure (HF) in developed countries exceeds 10% in adults over 70 year old. At the following report we aim to present a case of HF worsening complicated by gout attack.

80-year old patient was admitted to the hospital, with the suspicion of pneumonia, because of 3-day history of dyspnoe, cough and fever. Patient reported redness, swelling and pain in the area of left elbow. Prior to admission patient was diagnosed with bursitis and treated with antibiotic without symptoms resolution. There was past medical history of atrial fibrillation, hypertension, intermittent claudication, COPD. One month before, patient was hospitalized due to HF worsening. Diuretics' dosage was increased at that time and symptoms resolved. On admission: blood pressure 145/88 mm Hg, HR 96/min irregular, saturation O2 88% without oxygen therapy. On physical examination, bilateral pulmonary crackles, redness, tenderness of left elbow were found. Laboratory tests demonstrated elevated parameters of inflammation - leukocytosis 13.4G/L, neutrophilia 11G/L, CRP 142.5 mg/L, but normal procalcitonin 0.27 ng/ml. Moreover, high NTproBNP 8573 pg/ml and hyperuricemia 13.1 mg/dl were detected. Chest X-ray indicated pulmonary venous congestion. ECG revealed atrial fibrillation with QRS rate of 100/min, left axis deviation. Therefore, gout attack was diagnosed and after colchicine administration symptoms resolved quickly.

Clinical signs including fever, elevated parameters of inflammation and dyspnoe justify pneumonia consideration in differential diagnosis. Importantly, non-infectious causes of inflammatory conditions, like gout must be also considered. Patients with HF often develop hyperuricemia due to diuretic treatment, aggravated catabolism and often co-prevalent chronic kidney disease.