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From the American College of Rheumatology

Rheumatology for Primary Care
  • Symptoms
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Crystalline Arthropathies Case Studies

Home ยป Crystalline Arthropathies Case Studies
Crystalline Arthropathies Case Studies
  • Case 1

  • Case 2

  • Case 1

A 45 yo M with past medical history of hypertension and diabetes, presents with severe acute pain and swelling of the left knee that started last night.

Questions to Ask

  • Inflammatory?
  • Joint pain that is worse in the morning or with inactivity, and better with use or activity?
  • Duration of symptoms?
  • Any other joints involved?
  • Previous episodes? Precipitating factors (e.g., consumption of alcohol, shellfish, red meat)?

Clinical Presentation & History

  • Reports previous similar episodes affecting both knees, right midfoot, both 1st MTPs 
  • First episode: 2 years ago, with 4 episodes in the past year
  • Pain typically starts at night or early morning and increases in severity over several hours
  • Skin over joint is extremely sensitive to touch and warm.
Diagnostic Workup
  • Recommended labs: CBC with diff, CMP, ESR, CRP, serum uric acid
  • Consider imaging: x-ray of L knee

Referrals

  • Arthrocentesis with synovial analysis (cell count+diff, crystal analysis, gram stain+culture)
  • Gout management
Differential Diagnosis

Treatment

  • Given high pretest probability of gout, can initiate treatment for acute gout with an anti-inflammatory therapy (colchicine or NSAIDs if no contraindications or systemic steroids) while awaiting results of synovial analysis and labs.
    • If choosing glucocorticoids, monitor HTN and diabetes
    • Colchicine should be started no later than 48 hours of flare onset to be most effective.
  • Case 2

A 70 yo M with crystal-proven gout, chronic renal disease, and diabetes presents with new knee pain and swelling with high fevers, malaise, chills, and night sweats after recent July 4th barbecue.

Questions to Ask

  • Inflammatory?
  • Joint pain that is worse in the morning or with inactivity, and better with use or activity?
  • Other joints involved?

Clinical Presentation & History

  • History of podagra with multiple gout flares per year since onset
  • Non-adherent to urate-lowering drug
  • Physical exam: both knees are warm, tender to touch, and suprapatellar effusion

Diagnostic Workup

  • Recommended labs: CBC with diff, CMP, CRP, ESR, RF, CCP, hepatitis B/C serologies, Quant TB
  • Consider imaging: knee x-rays
  • Arthrocentesis with synovial analysis (cell count and diff, crystal analysis, gram stain, and culture)
Differential Diagnosis

Treatment

  • Acute therapy: consider colchicine and/or NSAIDs if no contraindications and avoid high dose systemic steroids or intra-articular steroids until infection ruled out.
    • Colchicine should be used with caution in patients with chronic renal disease. 

Next Steps

  • Given fevers, patient may need emergency department/inpatient evaluation to evaluate for/rule out infection.

Differential Diagnosis

Patient has a high pretest probability of gout.

Differential Diagnosis

Presence of systemic symptoms and potential sick contacts raises concern for infection.

Recent potential exposure to red meat +/- beer +/- dehydration and AKI raises concern for gout flare.

Related Content

Crystalline Arthropathies Overview

 

ACR Gout Treatment Guideline

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Primary Care2024-05-21T13:42:58+00:00

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