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
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.
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)
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.