A 64-year-old man is evaluated on postoperative day 3 following an uncomplicated partial c… — USMLE Step 2 CK

A $64$ -year-old man is evaluated on postoperative day $3$ following an uncomplicated partial colectomy for a diverticular stricture. He reports the abrupt onset of excruciating pain, swelling, and redness in his right knee that woke him from sleep. His temperature is $38.3^\circ\text{C}$ ( $100.9^\circ\text{F}$ ), blood pressure is $135/85\text{ mm Hg}$ , and heart rate is $98\text{/min}$ . Physical examination reveals a markedly swollen, warm, and erythematous right knee. Any range of motion elicits severe pain. Laboratory studies show a serum creatinine of $2.4\text{ mg/dL}$ (baseline $2.2\text{ mg/dL}$ ) and a serum uric acid level of $5.5\text{ mg/dL}$ . Arthrocentesis is performed, yielding cloudy yellow fluid with a leukocyte count of $35,000/\mu\text{L}$ ( $85\%$ neutrophils). Polarized light microscopy demonstrates numerous needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate next step in management for this patient's joint symptoms?

A
Administration of intravenous vancomycin and ceftriaxone
Intra-articular triamcinolone injectionAnswer
C
Initiation of oral allopurinol
D
Administration of oral naproxen
E
Observation pending synovial fluid culture results

Answer

The most appropriate next step in management is an intra-articular triamcinolone injection.

The correct answer provides targeted, local anti-inflammatory therapy that is highly effective for an acute gouty flare. Because the patient has pre-existing chronic kidney disease (creatinine

2.2\text{ mg/dL}

), first-line systemic agents like NSAIDs (naproxen, indomethacin) are contraindicated due to the risk of exacerbating renal failure. Colchicine is also generally avoided or requires severe dose reduction in advanced renal dysfunction. Therefore, an intra-articular glucocorticoid injection is the safest and most appropriate choice for a monoarticular flare.

Step-by-Step Solution

Analyze the clinical presentation and synovial fluid results.

The patient has acute monoarticular arthritis with needle-shaped, negatively birefringent crystals. The diagnosis is an acute gout flare, which is commonly triggered by physiological stressors such as surgery.

To establish the primary etiology of the joint inflammation and postoperative fever.

Evaluate the patient's comorbidities and laboratory values.

The patient has underlying chronic kidney disease, evidenced by a baseline creatinine of

2.2\text{ mg/dL}

that is currently

2.4\text{ mg/dL}

To determine the safety profile of available pharmacologic options for acute gout.

Select the most appropriate acute gout therapy based on contraindications.

Intra-articular glucocorticoids are chosen. NSAIDs are contraindicated in renal failure, and colchicine requires significant caution or is contraindicated in severe chronic kidney disease.

To safely provide rapid anti-inflammatory relief while minimizing systemic toxicity.

Key Concept

In patients with acute monoarticular gout flares and comorbid chronic kidney disease, intra-articular glucocorticoids are the preferred treatment to avoid the nephrotoxicity of NSAIDs and the systemic accumulation of colchicine.

Estimated Time:1m 15s

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