Question of the Week # 269

269 )  A 42 year old man is evaluated in the Emergency room for sudden onset pain and swelling in the right knee. He denies any trauma. His past medical history is significant for chronic alcohol abuse, diabetes and stage III chronic kidney disease.  On physical examination, temperature is 100.5F and heart rate 110. Right knee is grossly swollen, warm, tender and erythematous. Rest of the physical examination is within normal limits. Arthrocentesis is performed and results reveal polymorphonuclear leucocytes of 50,000/µl and intra-cellular negatively birefringent needle shaped crystals under polarized microscopy. Synovial fluid gram stain is negative and bacterial cultures are pending. Complete blood count shows a white blood cell count of 18,000/µl with left shift. Which of the following is the most appropriate management recommendation?

A) Colchicine

B) Indometacin

C) Oral Prednisone

D) Broad spectrum antibiotics

E) Intra-articular Triamcinolone

16 Responses

  1. d

  2. oral prednisone

  3. I think it is Oral steroids as it is Acute Gout in patient with kidney disease

  4. intra articular steroids as its gout in renal failure pt

  5. Oral prednisolone

  6. why should we not give indomethacin(because it is nephrotoxic -are is there any other reason)

  7. This is genius question . hahah

    i think the answer is D

    This patient definitely has GOUT : clue is negative birefringent needles . However , septic arthritis as complication can developed although rarely . Clue given by neutrohpil counts >50,000 .

    So our management is driven by whether should we treat Gout or Septic arthritis or both ?

    I would say we addressed septic arthritis first because it can lead to severe joint destruction .

    mainstay of tx : AB and surgery for lavage and debridment .

    Steroid whether intra articular or oral i think would not do good in septic arthritis especially in a acute period and there’s not enough information to prove its effectiveness as one of the mainline treatment .

    Just my 2 cents . Please do correct me if I’m wrong . thanks

  8. Answer E) for me. Gouty arthritis with renal failure _ Intraarticular steriod injection
    ??? Do We still need to treat as Septic arthritis – which is more dangerous?
    Dr. Red,
    please give answer for this question.

  9. e
    above 50,000 septic
    50,000 could be acute gout

  10. Answer E

    The joint fluid is inflammatory in nature with white cell counts as high as 60,000/mm3 with a neutrophil predominance. Infection may coexist with an acute gouty attack, so a Gram stain and culture should be performed.

    Corticosteroids (PO or intra-articular) can be used to terminate an acute gouty attack when both NSAIDs and colchicine are contraindicated. The intra-articular route is preferred over oral steroids if the attack involves a single joint, but infection should always be ruled out prior to administering steroids.

  11. Answer D. WBC 18,000/µl with left shift.

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