A 56-year-old man comes to the Emergency Room on a Sunday morning with a severely painful, red, and swollen left great toe, which had awakened him from a stuporous sleep. He has had 10 or 12 similar episodes over the past eight years, including one at age 51, one at age 53, two last year, and four this current year. He describes himself as a “binge” drinker. He has just completed seven consecutive days of being too drunk to make it to work at his job at the local battery factory.

His medical history includes hypertension and angina. One year ago, he was started on a diuretic, an angiotensin-converting enzyme inhibitor, and one aspirin per day. He says that he had been taking the medications because his family has a history of high blood pressure, heart attacks, and kidney stones.

On physical examination, his vital signs include a temperature of 101^oF, pulse 120/minute, and blood pressure 160/100. His weight is 210 lbs. and height 5’9"; he has a plethoric complexion, bulbous nose, and swelling with nodules over the right olecranon bursa, the extensor tendons of the left second finger, and on the helix of the ear.

His left first MTP joint was purple-red and so painful that he will not allow the examiner to attempt to flex the toe. Erythema and swelling extend up the midfoot. The other MTPs are not tender to light palpation.

A. Trauma
B. Crystal-induced arthritis
C. Psoriatic arthritis
D. Bacterial septic arthritis
E. Rheumatoid arthritis
F. Osteoarthritis
G. Reiter’s syndrome
H. Cellulitis

A. CBC with differential, BUN, creatinine, liver enzymes, uric acid, and urinalysis
B. Arthroscopy
C. ANA and RF
D. Aspirate the symptomatic MTP joint
E. Blood cultures
F. X-ray feet
G. X-ray hands
H. Aspirate right knee

Laboratory data include a WBC count of 12,200/mm³ (85% PMNs, 10% bands, 9 lymphs, 1 mono), Hgb 13.6 g/dl, Hct 41.0%, and platelets 386,000/mm³. Westergren sedimentation rate is 34 mm/hr. Serum calcium is 9.2 mg/dl, phosphorus 4.3 mg/dl, AST (SGOT) 70 IU/liter, ALT (SGPT) 23 IU/liter, LDH 120 IU/liter, alkaline phosphatase 106 IU/liter, bilirubin 1.0 mg/dl, uric acid 9.4 mg/dl, BUN 24 mg/dl, and creatinine 1.2 mg/dl. Urinalysis is normal. ANA and RF are negative.

Aspiration of the left first MTP joint yields only three drops of fluid. Therefore, a full synovial fluid analysis could not be performed. Gram stain of the fluid reveals many polymorphonuclear leukocytes, but no organisms. Polarizing light microscopy also shows many PMNs. The SF contains intra- and extracellular needle-shaped crystals, which are yellow when aligned parallel to the slow axis of rotation of the first-order red compensator in the polarizing microscope.

X-ray of the feet shows soft-tissue swelling around the left first MTP and erosion of that joint with an overhanging edge. No fracture is seen.

A. Rheumatoid arthritis
B. Gout
C. Calcium pyrophosphate dihydrate crystal-deposition disease (pseudogout)
D. Cholesterol crystal arthritis
E. Hydroxyapatite crystal arthritis
F. Septic arthritis
G. Cellulitis

A. IV antibiotic
B. IV colchicine
C. Oral colchicine
D. Short-acting NSAID (not ASA)
E. Intraarticular steroid injection
F. Oral prednisone
G. Allopurinol
H. ACTH

Question 5: In addition to his other problems, the patient has hyperuricemia.  Which six of the following may be associated with or are risk factors for his hyperuicemia?

A. Obesity
B. Ethanol use
C. Hypertension
D. Lead exposure
E. Smoking
F. Diuretic use
G. Low-dose aspirin use
H. Angiotensin-converting enzyme inhibitor use

The patient returns to the office eight weeks later and has been taking colchicine 0.6 mg twice daily as you prescribed. In addition, he was taken off the diuretic and now has no evidence of joint inflammation on examination. The serum uric acid is now 10.2 mg/dl. The 24-hour urinary uric acid is 780 mg in a total volume of 1.5 liters (off diuretics).

A. Discharge him from your clinic
B. Advise returning for treatment when arthritis flares
C. Treat the hyperuricemia with allopurinol
D. Treat the hyperuricemia with probenecid
E. Continue colchicine 0.6 mg bid
F. Counsel patient regarding medications, alcohol, and diet

A. Allopurinol
B. Probenecid
C. Colchicine prophylaxis
D. Counseling regarding potential risk factors
E. No recommendations are needed

After working this case, the student should be able t

1. List the most important tests for the diagnosis of acute monarticular arthritis.
   
   
2. List the major diagnostic considerations in a patient with acute monarticular arthritis.
   
   
3. Name the color of monosodium urate and CPPD crystals on polarized light microscopy when the long axis of the crystal is parallel to the slow axis of the first order red compensator.
   
   
4. Name the major drugs used to treat acute gouty arthritis.
   
   
5. List at least two indications for initiating treatment of chronic hyperuricemia.

American College of Rheumatology Ad Hoc Committee on Clinical Guidelines: Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. Arthritis Rheum 1996;39:1-8.

Bomalski JS, Schumacher HR. Podagra is more than gout. Bull Rheum Dis 1984;34:1-8.

Edwards NL. Drugs used to lower uric acid levels. Postgrad Med 1991;89:111-116.

Emmerson BT. The management of gout. N Engl J Med 1996;334:445-451.

Groff GD, Franck WA, Raddatz DA. Systemic steroid therapy for acute gout: a clinical trial and review of the literature. Semin Arthritis Rheum 1990;19: 329-336.

Schumacher HR Jr, Reginato AJ. Atlas of synovial fluid analysis and crystal identification. Philadelphia: Lea & Febiger; 1991.

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