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Contributor: Santhanam Lakshminarayanan, MD
Rheum2Learn cases contain links to images in the Rheumatology Image Library. Access to the Library is an ACR/ARP member benefit. See information about membership types and how to become a member.
A 78 year old man is seen in the clinic for a painful swelling of the left elbow. Over the past year, he has had a few episodes of pain and swelling in his right knee and left foot, for which he received ibuprofen and once was treated with an antibiotic. His elbow is shown in the picture. He also has hypercholesterolemia and hypertension and is on simvastatin, hydrochlorothiazide and metoprolol.
He drinks several beers a day but does not smoke.
His exam is remarkable only for the appearance of his hands, similar to the picture shown.
What is the most appropriate next step, respectively?
Aspiration of the olecranon bursa was performed. Findings under polarized microscopy showed the presence of intracellular negatively birefringent crystals. Treatment consists of injection of steroids (in the absence of an obvious infection) into the olecranon bursa. In addition to intra-articular injections, other treatments for acute gout include NSAIDs, colchicine, and oral glucocorticoids. Urate-lowering therapy should not be initiated during an acute attack. If a patient is already on urate-lowering therapy or it was briefly interrupted, it should be continued or restarted.
Having established the diagnosis and provided relief for the acute problem what are the next steps in the management of this patient?
You are asked to see an elderly lady admitted to the hospital for pneumonia 4 days ago. She has a painful swollen wrist with no antecedent history of a fall. The hospitalist team did an x-ray of the wrist and hand. The wrist is minimally warm and tender with some decreased range of motion secondary to pain. The pneumonia is improving and she was looking forward to being discharged on oral antibiotics. She mentioned that she had bumped her knee on the dresser on the day of admission and had an x-ray.
What is your diagnosis?
What is the most appropriate intervention?
Aspiration of the synovial fluid from the wrist for analysis, and intra-articular Injection of steroids (in the absence of any obvious infection). The fluid may show weakly positively bi-refringent crystals.
What chronic management is indicated?
CPPD is common in older individuals, especially with osteoarthritis. In younger people, a work-up for secondary causes of CPPD is indicated. Therefore, screening for hemochromatosis, hypothyroidism, hyperparathyroidism and disorders of magnesium and phosphatase are indicated. In the absence of a secondary cause, chronic intervention is usually not needed, or very effective.
(Answer questions 1 – 5 on a piece a paper. The Answer Key is at the bottom of the page.)
1. An 80 year old man presents with an acutely swollen R ankle and with erythema and pain. He has a known history of gout with previous attacks in both the first MTP of the R foot and the L ankle. He has Chronic kidney disease, atrial fibrillation and hyper- cholesterolemia and is on Furosemide, Lisinopril , Metoprolol, coumadin and a statin. He continues to drink alcohol liberally. His laboratory tests reveal WBC 3200/µL, platelets 100,000/µL, Hb 9.8g/dL, creatinine 3.6mg/dL, uric acid 9.0mg/dL and INR 4.0. The most appropriate management step in this patient is:
2. A previously healthy 70 year old lady is admitted with pneumonia and on the 2nd day of hospitalization develops a painful swollen R knee with tenderness and warmth. She is afebrile. The rest of her articular exam is normal except for nodular osteoarthritis of her hands and crepitus in the L knee. The most appropriate first step in her management is:
3. You are asked to evaluate a currently asymptomatic 67 year-old man who has a long history of gout. During the past six months, he has had multiple acute gouty flares involving the left wrist, the right knee, and the first metatarsophalangeal joints. A year ago, he underwent heart transplantation because of viral cardiomyopathy. At that time, his regimen of allopurinol, 300 mg daily, and colchicine, as needed for acute flares, was discontinued. He has taken no regular medication for gout since then, except for indomethacin during the recent flares.
Current medications are cyclosporine, 400 mg; azathioprine, 100 mg daily, and prednisone, 10 mg daily. Physical examination reveals a tophus in the left olecranon bursa. No joint tenderness or swelling is present. Leukocyte count is 7500/cu mm with a normal differential. Serum creatinine level is 1.8 mg/dL. Serum uric acid level is 10.6 mg/dL. The best treatment plan for this patient is:
4. A 46-year-old man is evaluated because of a three-month history of progressive generalized weakness without pain and the recent onset of numbness in the hands and toes. For the past three weeks, the patient has required support while walking and assistance in rising from a chair. Medical history includes hypertension and two attacks of gout. He has taken colchicine, 0.6 mg twice daily, for the past four years, and he currently takes hydrochlorothiazide, 50 mg daily. He drinks 2 to 3 cans of beer daily. At the time of physical examination, the patient cannot stand or walk without assistance. Blood pressure is 160/100 mm Hg. There is marked symmetric proximal muscle weakness which is more severe in the legs. Sensation to pinprick and vibration is decreased in the toes. Deep tendon reflexes are absent.
Hemoglobin 12.5 g/dL
Mean corpuscular volume 99 fL
Erythrocyte sedimentation rate 32 mm/hr
Serum aspartate aminotransferase 125 U/L (AST)
Serum creatinine 1.9 mg/dl
Serum creatine kinase 2010 U/L
Serum uric acid 8.0 mg/dL
Which of the following is the most likely diagnosis?
Which of the following findings on synovial fluid analysis is consistent with an asymptomatic lady with a minimal knee effusion that was aspirated after obtaining the X- ray below?
(Answer questions 1 – 5 on a piece a paper. Find Answer Key at the bottom on the page.)
Last updated February 2015.