A 65-year-old man develops severe right knee pain, swelling, and a temperature of 38.2°C (100.8°F) on postoperative day 3 following an uncomplicated inguinal hernia repair. His medical history is significant for hypertension and stage 3 chronic kidney disease. Examination reveals a markedly swollen, erythematous, and exquisitely tender right knee. Arthrocentesis yields cloudy yellow synovial fluid. Analysis shows a leukocyte count of 35,000/mm³ with 85% neutrophils. Polarized light microscopy reveals needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate next step in management?
- Intra-articular glucocorticoid injectionAnswer
- BIntravenous vancomycin and ceftriaxone
- CStart oral indomethacin
- DOrder blood cultures, urinalysis, and a chest radiograph
- EMeasure serum uric acid level
Answer
Intra-articular glucocorticoid injection is the most appropriate initial therapy.
The patient is experiencing an acute gout flare, which frequently occurs in the postoperative period due to physiologic stress, fasting, or fluid volume shifts. The diagnosis is definitively confirmed by the presence of needle-shaped, negatively birefringent monosodium urate crystals in the synovial fluid. The most appropriate initial treatment for a monoarticular gout flare in a patient with chronic kidney disease (CKD) is an intra-articular glucocorticoid injection. Standard first-line systemic therapies, such as NSAIDs (e.g., indomethacin) and colchicine, are strongly contraindicated in patients with significant renal impairment due to the high risk of nephrotoxicity and impaired drug clearance, respectively.
Step-by-Step Solution
Key Concept
Management of acute gout flares in patients with chronic kidney disease