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Difficulty: EasyRheumatology and Immunology

A 52-year-old man presents to the urgent care clinic due to severe pain, redness, and swelling in his left big toe. The symptoms started abruptly early this morning and have progressively worsened, making it difficult for him to walk. He has a medical history of hypertension, for which he takes hydrochlorothiazide. His temperature is 37.2°C (99.0°F), blood pressure is 135/85 mm Hg, and pulse is 88/min. Physical examination reveals a remarkably tender, erythematous, and warm left first metatarsophalangeal joint with significant swelling. An arthrocentesis is performed, and synovial fluid analysis demonstrates a leukocyte count of 25,000/mm³ with negatively birefringent, needle-shaped crystals under polarized light microscopy. Gram stain of the fluid shows no organisms, and his serum creatinine is 0.9 mg/dL. Which of the following is the most appropriate next step in the management of this patient?

  1. Administration of oral naproxenAnswer
  2. B
    Initiation of daily allopurinol
  3. C
    Administration of intravenous vancomycin
  4. D
    Measurement of serum uric acid level
  5. E
    Measurement of antinuclear antibodies

Answer

Administration of oral naproxen
The correct answer is administration of oral naproxen. This patient presents with a classic acute flare of gout, characterized by severe, rapid-onset monoarthritis of the first metatarsophalangeal joint (podagra). The diagnosis is definitively established by synovial fluid analysis demonstrating needle-shaped, negatively birefringent monosodium urate crystals. The use of hydrochlorothiazide is a known risk factor, as thiazide diuretics decrease the renal excretion of uric acid. For the management of an acute gout flare, first-line therapies include nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen or indomethacin, colchicine, or glucocorticoids. Given the patient's normal serum creatinine and lack of stated contraindications, an NSAID is a highly effective and appropriate initial therapy to reduce acute inflammation.

Step-by-Step Solution

1
Analyze the clinical presentation and physical exam findings.
The patient has acute, highly inflammatory monoarticular arthritis of the first metatarsophalangeal joint (podagra), strongly suggesting a crystal-induced arthropathy or infectious etiology.
Identifying the clinical syndrome is the first step in formulating a differential diagnosis.
2
Interpret the synovial fluid analysis.
The fluid shows a moderately elevated leukocyte count (25,000/mm³) and negatively birefringent needle-shaped crystals, with a negative Gram stain.
These findings definitively confirm the diagnosis of acute gout caused by monosodium urate crystals and rule out septic arthritis.
3
Determine the most appropriate initial therapy for the confirmed diagnosis.
Oral NSAIDs (such as naproxen, indomethacin, or ibuprofen), colchicine, or systemic/intra-articular corticosteroids are the mainstays of acute gout treatment.
Since the patient has normal renal function (creatinine 0.9 mg/dL) and no stated contraindications, an oral NSAID is the most appropriate next step to quickly resolve the severe inflammation.

Key Concept

The diagnosis of acute gout is confirmed by the presence of negatively birefringent, needle-shaped monosodium urate crystals in synovial fluid. First-line therapy for an acute flare includes NSAIDs, colchicine, or corticosteroids.
Estimated Time:1m 0s
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Topics

Rheumatology and Immunology

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