A physician is asked to evaluate a hospitalized 72-year-old male on postoperative day 4 fo… — USMLE Step 2 CK

A physician is asked to evaluate a hospitalized $72$ -year-old male on postoperative day $4$ following an emergency exploratory laparotomy and small bowel resection for a strangulated hernia. Overnight, he developed an acute fever of $38.4^\circ\text{C}$ ( $101.1^\circ\text{F}$ ) and excruciating pain in his right knee.

The patient has a history of hypertension and chronic kidney disease, with a baseline serum creatinine of $2.1\text{ mg/dL}$ . He is currently receiving continuous intravenous fluids and is transitioning to a clear liquid diet.

On physical examination, his vital signs are stable aside from the fever. The right knee is markedly swollen, uniformly erythematous, warm, and exquisitely tender to light palpation. He refuses to range the joint. The surgical incision site is clean, dry, and intact with no surrounding erythema or induration.

Arthrocentesis of the right knee is performed, yielding $5\text{ mL}$ of cloudy yellow fluid. Synovial fluid analysis reveals:

- Leukocyte count: $45,000/\text{mm}^3$ ( $85\%$ neutrophils)
- Gram stain: No organisms seen
- Crystal analysis: Negatively birefringent, needle-shaped crystals

Which of the following is the most appropriate next step in the management of this patient's joint condition?

Administer an intra-articular injection of triamcinoloneAnswer
B
Initiate empiric intravenous vancomycin and ceftriaxone
C
Obtain a computed tomography scan of the abdomen and pelvis
D
Prescribe oral indomethacin
E
Administer intravenous furosemide

Answer

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

The correct answer involves administering an intra-articular glucocorticoid injection. This patient has an acute gout flare, definitively diagnosed by the negatively birefringent, needle-shaped crystals. A key principle in rheumatology is tailoring acute flare management to the patient's comorbidities. This patient has advanced chronic kidney disease (precluding the use of NSAIDs like indomethacin) and is recovering from a major intestinal resection (making oral colchicine poorly tolerated and systemic glucocorticoids risky due to potential impairment of anastomotic healing). Intra-articular triamcinolone provides rapid, localized relief without significant systemic side effects.

Step-by-Step Solution

Diagnose the underlying condition based on synovial fluid analysis.

The presence of negatively birefringent, needle-shaped crystals confirms acute monosodium urate crystal arthropathy (gout).

Accurate diagnosis is required to distinguish crystal arthropathy from septic arthritis, as both can present with high synovial leukocyte counts and fever.

Evaluate the safety profile of standard gout therapies against the patient's comorbidities.

NSAIDs are contraindicated due to chronic kidney disease (Cr 2.1 mg/dL). Colchicine is high-risk in CKD and post-bowel resection. Systemic steroids could impair surgical anastomotic healing.

Pharmacotherapy for acute gout must be individualized to prevent severe iatrogenic complications like acute kidney injury or bowel perforation.

Select the optimal targeted therapy.

Intra-articular glucocorticoid injection is selected.

It provides powerful, localized anti-inflammatory effects with minimal systemic absorption, making it the safest choice for this complex postoperative patient.

Key Concept

The management of acute monoarticular gout in patients with significant comorbidities (such as chronic kidney disease or recent gastrointestinal surgery) requires targeted local therapy, such as intra-articular glucocorticoids, to avoid the severe systemic toxicities associated with NSAIDs, colchicine, and systemic steroids.

Estimated Time:1m 30s

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