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Difficulty: MediumRheumatology and Immunology

A 65-year-old man is evaluated on postoperative day 3 for acute-onset right knee pain and swelling. The patient underwent an uncomplicated laparoscopic cholecystectomy for acute calculous cholecystitis. His medical history is significant for hypertension, type 2 diabetes mellitus, and chronic kidney disease. His home medications include amlodipine, insulin glargine, and atorvastatin. His temperature is 38.2°C (100.8°F), blood pressure is 145/85 mm Hg, pulse is 95/min, and respiratory rate is 16/min.

Physical examination shows a swollen, erythematous, and exquisitely tender right knee with a large effusion. Range of motion is severely limited due to pain. The surgical incisions are clean, dry, and intact.

Laboratory studies show:
TestResult
Leukocyte count12,500/mm³
Serum creatinine2.6 mg/dL (baseline 2.4 mg/dL)

Arthrocentesis of the right knee is performed. Synovial fluid analysis shows a leukocyte count of 45,000/mm³ with 85% neutrophils. Polarized light microscopy reveals negatively birefringent, needle-shaped crystals. Gram stain of the synovial fluid shows no organisms.

Which of the following is the most appropriate next step in management?

  1. A
    Intravenous vancomycin and ceftriaxone
  2. B
    Blood and urine cultures with chest radiography
  3. Intra-articular triamcinolone injectionAnswer
  4. D
    Oral naproxen
  5. E
    Measurement of serum uric acid level

Answer

Intra-articular triamcinolone injection
The correct answer is intra-articular triamcinolone injection. The patient is experiencing an acute gout flare, evidenced by severe monoarticular inflammation and the presence of negatively birefringent, needle-shaped crystals in the synovial fluid. Postoperative status is a classic trigger for gout due to fluid shifts and systemic stress. First-line treatments for acute gout include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids. However, this patient's severe chronic kidney disease (creatinine 2.6 mg/dL) represents an absolute contraindication to NSAID therapy. Colchicine must also be heavily dose-adjusted or avoided in advanced renal failure. While oral systemic corticosteroids are an option, they may significantly disrupt glycemic control in a patient with type 2 diabetes. Therefore, an intra-articular corticosteroid injection is the most appropriate and targeted next step, maximizing local anti-inflammatory efficacy while minimizing systemic adverse effects.

Step-by-Step Solution

1
Diagnose the underlying condition.
Acute gout flare.
The patient has acute monoarthritis with negatively birefringent, needle-shaped crystals on synovial fluid analysis, which is diagnostic for gout. The flare was likely precipitated by surgical stress and fluid shifts.
2
Identify relevant patient comorbidities.
Severe chronic kidney disease and type 2 diabetes mellitus.
The laboratory panel shows a markedly elevated serum creatinine, indicating significant baseline renal impairment.
3
Select the safest first-line therapy.
Intra-articular corticosteroid injection.
NSAIDs are contraindicated due to the chronic kidney disease. Systemic corticosteroids could exacerbate his diabetes. For a single affected joint, an intra-articular injection provides rapid relief with minimal systemic side effects.

Key Concept

Management of acute gout flares must be tailored to patient comorbidities. NSAIDs and colchicine are often contraindicated in severe chronic kidney disease, making intra-articular corticosteroids the preferred treatment for monoarticular involvement.
Estimated Time:1m 15s
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Topics

Rheumatology and Immunology

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