Internal Medicine · Year 3 · from Internal Medicine

Case 3: Gout

Patient Presentation

A 54-year-old man presents with acute onset of severe left first metatarsophalangeal (MTP) joint pain that woke him from sleep 12 hours ago. The pain is so intense he cannot bear weight or tolerate even bedsheet contact. He had a similar episode 6 months ago that resolved spontaneously. He has a history of hypertension treated with hydrochlorothiazide and reports drinking 2-3 beers most nights.

Vital Signs

  • Blood Pressure: 148/92 mmHg
  • Heart Rate: 88 bpm
  • Temperature: 37.8°C

Physical Examination

  • General: In significant pain
  • Left foot: First MTP joint is exquisitely tender, swollen, erythematous, and warm; overlying skin is shiny and taut
  • Right foot: Normal
  • Hands: No tophi
  • Ears: No tophi

Laboratory Results

  • Serum uric acid: 9.8 mg/dL (elevated, normal <6.8)
  • WBC: 12,400/μL
  • Creatinine: 1.3 mg/dL
  • Joint aspiration: Cloudy fluid, WBC 42,000/μL (predominantly neutrophils), negatively birefringent needle-shaped crystals

Clinical Image

Figure 3: Acute gouty arthritis of the first metatarsophalangeal joint (podagra) showing intense erythema, swelling, and characteristic taut, shiny overlying skin.

Image Source: Educational illustration for teaching purposes.

Questions

  1. What finding on joint aspiration confirms the diagnosis of gout?
  • A) Elevated WBC count
  • B) Negatively birefringent needle-shaped monosodium urate crystals
  • C) Positive culture
  • D) Low glucose
  1. What is the appropriate acute treatment for this gout flare?
  • A) Allopurinol
  • B) NSAIDs, colchicine, or corticosteroids (but NOT urate-lowering therapy acutely)
  • C) Probenecid
  • D) Increased hydration only
  1. What risk factors for gout does this patient have?
  • A) Young age
  • B) Thiazide diuretic use, alcohol consumption, elevated uric acid, male sex
  • C) Vegetarian diet
  • D) Low BMI
  1. When should urate-lowering therapy be initiated?
  1. What is the target serum uric acid level for gout management?

Answers

  1. B) Negatively birefringent needle-shaped monosodium urate crystals - Definitive diagnosis:
  • Joint aspiration is gold standard
  • MSU crystals are needle-shaped and show negative birefringence (yellow when parallel to polarizer axis)
  • Pseudogout (CPPD) crystals are rhomboid and show positive birefringence (blue when parallel)
  • High WBC suggests inflammatory arthritis but is not specific
  • Always rule out septic arthritis if clinically suspected
  1. B) NSAIDs, colchicine, or corticosteroids (but NOT urate-lowering therapy acutely) - Acute treatment:
  • NSAIDs: Indomethacin 50 mg TID or naproxen 500 mg BID (avoid if CKD, GI risk, or cardiovascular disease)
  • Colchicine: 1.2 mg initially, then 0.6 mg 1 hour later; then 0.6 mg daily-BID (best if started within 12-24 hours)
  • Corticosteroids: Prednisone 30-40 mg/day tapered over 7-10 days OR intra-articular injection
  • Do NOT start allopurinol during acute flare (can prolong/worsen flare)
  1. B) Thiazide diuretic use, alcohol consumption, elevated uric acid, male sex - Risk factors:
  • Thiazides decrease uric acid excretion
  • Alcohol (especially beer) increases uric acid production and decreases excretion
  • Male sex (premenopausal women protected by estrogen)
  • Obesity, metabolic syndrome
  • Chronic kidney disease
  • Diet high in purines (organ meats, shellfish)
  • Certain medications (cyclosporine, low-dose aspirin)
  1. When to initiate urate-lowering therapy:
  • ≥2 flares per year
  • Presence of tophi
  • Radiographic evidence of gouty erosions
  • Chronic kidney disease (stage ≥2)
  • History of urolithiasis
  • Consider for any patient after first flare if comorbidities present
  • Wait until acute flare resolves (or at least 2 weeks) before starting
  • Provide flare prophylaxis (colchicine 0.6 mg daily-BID) for 3-6 months when starting
  1. Target serum uric acid:
  • Goal: <6.0 mg/dL (below saturation point of 6.8 mg/dL)
  • More stringent goal <5.0 mg/dL for severe/tophaceous gout
  • Allopurinol: First-line; start low (100 mg), titrate to goal
  • Febuxostat: Alternative xanthine oxidase inhibitor
  • Probenecid: Uricosuric agent; avoid if CKD or nephrolithiasis
  • Treat-to-target approach with regular uric acid monitoring

Learning Points

  1. Rheumatoid arthritis is a symmetric inflammatory polyarthritis affecting MCP/PIP joints; anti-CCP is highly specific; methotrexate is first-line DMARD.
  1. Systemic lupus erythematosus is a multisystem autoimmune disease; anti-dsDNA and anti-Smith are specific; hydroxychloroquine is foundational therapy; lupus nephritis requires renal biopsy.
  1. Gout is diagnosed by negatively birefringent needle-shaped MSU crystals; treat acute flares with NSAIDs/colchicine/steroids; urate-lowering therapy targets uric acid <6.0 mg/dL.
  1. Joint aspiration is essential when crystal arthropathy or septic arthritis is suspected.
  1. Early and aggressive treatment of inflammatory arthritis prevents joint damage and disability.

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