Endocrine Case Report: White Paste

History of Present Illness:

A pleasant 53-year-old male with a history of obesity, DM on glucophage, and HTN on Lasix presents to the ER with one month of migratory bilateral ankle pain, currently worse on the left. He has seen many doctors, had x-rays and been prescribed orthotics, but no one is sure of the cause and he has not been able to work for the past two weeks due to severe worsening pain. He denies any fever, injury, increase in activity prior to symptom onset, calf swelling, chest pain, shortness of breath, or other complaints.

Vitals & Physical Exam:

Vital signs are normal except for a blood pressure of 172/98. His physical exam is normal except for some mild bilateral ankle tenderness. He is quite obese, so you cannot really tell if the ankles are swollen or just fat, but they look symmetric. There is no redness. There seems to be slight warmth on the left, compared to the right ankle.

Differential Diagnosis:

• Osteoarthritis
• Gout
• Infection

Initial Testing:

• X-ray of the ankles showed mild osteoarthritis.
• The left ankle joint was tapped but no fluid was obtained. After removal of the needle, the plunger was pulled back a bit more to make sure there was no fluid in the needle lumen or hub. None was noted. Right before the doctor was about to throw away the syringe, a small amount of white paste about 1 mm x 1 mm was noted. See image below of the paste after it was flattened up against the distal end of the syringe to check consistency and better visualize it.