2] A 57-year-old man
comes to the emergency department because of excruciating pain in his right big toe
. He describes the pain as so severe that it woke him from a deep sleep. He has no chronic medical conditions, does not take any medications, and denies any similar episodes in the past
. He admits to a few "drinking
binges" over the past 2 weeks. His temperature is 38.1 C
(100.5 F), blood pressure is 130/90 mm Hg, and pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender
right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals
within polymorphonuclear leukocytes (PMNs). Laboratory studies show: Serum
Leukocytes........16,000/mm3Uric acid...........15 mg/dL
Calcium.............9 mg/dL Which of the following is the most appropriate pharmacotherapy?
In order to manage a case of joint disease, we must answer the following 4 questions: (this case is a very typical one that can be diagnosed immediatly but we are talking about systematic approach to arthritis in general)1-Is it mono/ oligo/ polyarthritis ?
2-Is it actute or chronic?
3-Is it inflamatory arthritis? [presence of red warm joint / morning stiffness>1 hr]
4-Is there any affection of other body systems? [skin / eye / lung / kindey /etc...]
well, another important question is to know if it's the joint affected or periarticular structure eg. tendon , bursa, etc.. [it'll be clear with examination]
try to apply this to our patient .......
........... What do you think??
A case of monoartritis
[it's only the big toe] - Acute
[no previous history] - Inflamatory
[erythematous and warm] - No other systems affected
Next question: what are the causes of acute mono arthritis?
? 3 condition : trauma, infection, and crystalline arthritis.What shall we do next
to identify the exact cause (after history and examination of course) ?
of the joint may be useful in documenting trauma or preexisting joint disease. Radiographs are usually normal in acute infectious or crystalline arthritis.? ? [we don't need it here as there is no history of trauma or preexisting disease, right? ]
B. Synovial fluid
should be aspirated in all patients with a monarticular arthritis who do not have a preexisting diagnosis that is consistent with the clinical picture. [ so we need synovial fluid aspiration]
? Synovial fluid cell counts [not mentioned in our case]
above 5000 nucleated cells/?l suggest an inflammatory etiology. Counts above 50,000 cells/?l may indicate infection, particularly if 75% or more of the cells are polymorphonuclear. Crystals
occur in cases of crystal induced arthritis [our case here]
? which includes gout, pseudogout, and apatite disease. A
efinitive diagnosis of gout or pseudogout is made by finding intracellular crystals in joint fluid examined with a compensated polarized light microscope. Urate crystals
, which are diagnostic of gout, are needle shaped and strongly negatively birefringent. The calcium pyrophosphate dihydrate crystals
seen in pseudogout are pleomorphic and weakly positively birefringent. Hydroxyapatite complexes
, diagnostic of apatite disease, and basic calcium phosphate complexes can be identified only by electron microscopy and mass spectroscopy.What kind of crystals are found in this case?
negatively birefringent, needle-shaped crystals so it's URATE.
So this is GOUT. Acute gout [as there is no previous history]
Another point in the diagnosis is that this is Acute Primary Gout
( as there is no identified cause for secondry gout) Here is a hint about secondry gout :
Intrinsic renal disease, diuretic therapy, low-dose aspirin, nicotinic acid, cyclosporine, and ethanol all interfere with renal excretion of uric acid. Starvation, lactic acidosis, dehydration, preeclampsia, and diabetic ketoacidosis also can induce hyperuricemia. Overproduction of uric acid occurs in myeloproliferative and lymphoproliferative disorders, hemolytic anemia, polycythemia, and cyanotic congenital heart disease.
Now we have the diagnosis , these are guidelines for the treatment , read them and you'll know the correct answer:
are the treatment of choice for acute gout due to ease of administration and low toxicity. Clinical response may require 12?24 hours, and initial doses should be high, followed by rapid tapering over 2?8 days. One approach is to use indomethacin, 50 mg PO q6h for 2 days, followed by 50 mg PO q8h for 3 days and then 25 mg PO q8h for 2?3 days. The long-acting NSAIDs generally are not recommended for acute gout. Selective COX-2 inhibitors have not been critically evaluated for treatment of gout but should also be effective.
are useful when NSAIDs are contraindicated. An intra-articular injection of glucocorticoids produces rapid dramatic relief. Alternatively, prednisone, 40?60 mg PO qd, can be given until a response is obtained and then should be tapered rapidly.
is most effective if given in the first 12?24 hours of an acute attack and usually brings relief in 6?12 hours. In view of the efficacy and tolerability of a short course of NSAIDs, colchicine is not commonly used to treat gout but is useful when NSAIDs or glucocorticoids are contraindicated or not tolerated. which one will you choose for this patient?