Philip D Welsby
Retired Consultant in Infectious Diseases,
University Teaching Fellow, University of Edinburgh
Two events of medical interest occurred during a recent visit to the Rocky Mountains and Colorado Springs. I developed gout in my left little toe within one week of arrival in Denver, the “mile high” city (5,280 feet) above sea level. Denver is technically a semi desert, having only 15.8 inches of rain a year, and has the third lowest humidity of all American cities. I had had an exactly similar attack of gout when I had previously visited the Rocky Mountains. Almost certainly the gout was precipitated by unappreciated dehydration, with water loss via increased ventilation (related to relative hypoxaemia at altitude and increased sweating). Why the little toe? I had severely dislocated this during a judo related incident as a medical student.
My 12-year-old grandson, who lives in Illinois (583 feet above sea level), developed central cramping abdominal pain a few days after arrival, later localising to the right iliac fossa. There was tenderness, rebound tenderness, and a positive psoas stretch test. He was however afebrile and, although having marked discomfort, was not systemically unwell. His urine was dark but not cloudy. Appendicitis was obviously a possibility. I thought, correctly, that he ought to be seen by a proper doctor who, to my slight embarrassment, diagnosed constipation (although my grandson had never had constipation before), and this was supported by a predominantly right sided loaded colon on X-ray. Apparently doctors practicing locally at high altitude see more severe forms of constipation, again because of unappreciated dehydration.
The learning point from these two episodes is that altitude-related dehydration can be more significant than superficial assessment might suggest, can cause significant problem, and local “high-altitude doctors” see a different spectrum of dehydration in recently arrived visitors than do “sea-level” doctors.