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Difficulty: EasyRheumatology and Immunology

A 55-year-old man comes to the urgent care clinic with sudden, severe pain and swelling in his right big toe that awoke him from sleep. He has a history of hypertension and recently recovered from a mild respiratory illness. Vital signs are within normal limits. Physical examination reveals a markedly erythematous, warm, and exquisitely tender right first metatarsophalangeal joint. Synovial fluid analysis shows a leukocyte count of 18,000/µL. Polarized light microscopy of the fluid reveals needle-shaped, negatively birefringent crystals, and the Gram stain is negative. Which of the following is the most appropriate initial management for this patient's current condition?

  1. Oral colchicineAnswer
  2. B
    Intravenous cefazolin and admit to the hospital
  3. C
    Oral allopurinol
  4. D
    Intravenous furosemide
  5. E
    Surgical debridement of the joint

Answer

Oral colchicine
The patient's presentation of podagra (inflammation of the first metatarsophalangeal joint) along with synovial fluid showing needle-shaped, negatively birefringent crystals confirms the diagnosis of an acute gout flare. First-line medical therapy for acute gout includes NSAIDs, colchicine, or glucocorticoids. Oral colchicine is highly effective when started early in the course of an attack.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and synovial fluid results.
The patient has acute monoarticular arthritis of the first metatarsophalangeal joint (podagra) with negatively birefringent, needle-shaped crystals.
Identifying the crystals is the definitive step to differentiate between various causes of acute monoarthritis.
2
Diagnose the underlying condition.
The diagnosis is an acute gout flare, caused by monosodium urate crystal deposition.
Negatively birefringent needle-shaped crystals are pathognomonic for gout, whereas pseudogout would show weakly positively birefringent rhomboid crystals.
3
Determine the most appropriate initial therapy.
First-line therapies for acute gout include NSAIDs, colchicine, or systemic glucocorticoids.
These agents rapidly reduce acute inflammation. Urate-lowering therapies are generally not initiated during an acute flare without concurrent anti-inflammatory prophylaxis.

Key Concept

Diagnosis and acute management of gout
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Topics

Rheumatology and Immunology

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