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Difficulty: EasyRheumatology and Immunology

A 54-year-old man develops severe pain, redness, and swelling of his right big toe on postoperative day 3 following an uncomplicated laparoscopic cholecystectomy. He cannot bear weight on the affected foot. His temperature is 37.6°C (99.7°F), blood pressure is 135/85 mm Hg, and pulse is 88/min. Examination shows an exquisitely tender, erythematous, and swollen right first metatarsophalangeal joint. Synovial fluid analysis reveals a leukocyte count of 22,000/mm³ and numerous negatively birefringent, needle-shaped crystals. Which of the following is the most appropriate next step in management?

  1. Administer oral indomethacinAnswer
  2. B
    Initiate oral allopurinol therapy
  3. C
    Administer intravenous vancomycin and ceftriaxone
  4. D
    Obtain a urinalysis and urine culture
  5. E
    Administer intravenous furosemide

Answer

Administer oral indomethacin
The correct answer is to administer an NSAID such as oral indomethacin. This patient presents with a classic acute gout flare (podagra), commonly precipitated by the physiological stress of surgery, changes in diet, or fluctuations in fluid status during hospitalization. The diagnosis is definitively established by the presence of negatively birefringent, needle-shaped monosodium urate crystals in the synovial fluid. The primary goal in acute gout management is the rapid reduction of inflammation, which is achieved through the use of NSAIDs, colchicine, or intra-articular/systemic corticosteroids.

Step-by-Step Solution

1
Analyze the clinical presentation and synovial fluid results.
The patient has an acute monoarthritis on postoperative day 3. The synovial fluid analysis demonstrates a moderately elevated leukocyte count with negatively birefringent, needle-shaped crystals.
Identifying the specific crystal characteristics is required to differentiate gout from other forms of acute arthritis, such as pseudogout or septic arthritis.
2
Synthesize the findings to establish a definitive diagnosis.
The clinical picture is diagnostic for an acute gout flare (podagra), which is frequently triggered by the physiological stress of recent surgery or hospitalization.
Establishing the correct etiology of the joint inflammation dictates the appropriate choice of pharmacotherapy.
3
Determine the most appropriate initial treatment for the diagnosed condition.
Nonsteroidal anti-inflammatory drugs (NSAIDs) like indomethacin, colchicine, or systemic corticosteroids are the appropriate first-line agents for an acute gout flare.
Acute gout requires rapid anti-inflammatory therapy. Urate-lowering medications should generally be avoided in the acute setting if the patient is not already taking them.

Key Concept

The diagnosis and acute management of a gout flare.
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Topics

Rheumatology and Immunology

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