How To Evaluate Monoarticular Joint Pain

January 10, 2018

In this episode of 'Beyond The Pearls', I explain how to evaluate monoarticular joint pain.  Take a look!


  • 45 year old man is evaluated in the ER for a 5-day history of acute swelling and pain of the right knee

  • He has a 15-year history of gout, with multiple attacks annually; he also has DM and CKD. Meds are enalapril, glipizide, and allopurinol

  • On exam, temp 100.8, BP 146/88, HR 96 and RR 15

  • Several nodules are noted on the MCP and PIP joints and within the olecranon bursa. The right knee is swollen, erythematous, warm, tender, and fluctuant

  • Radiographs of the knee reveal soft-tissue swelling

  • Aspiration drainage of the right knee is performed:

    • Synovial fluid leukocyte count is 110,000/µL (88% PMN)

    • Polarized light microscopy of the fluid demonstrates extracellular and intracellular negatively birefringent crystals

    • Gram stain is negative for bacteria

    • Culture results are pending


  • Which of the following is the most appropriate initial treatment?

  1. Intra-articular methylprednisolone

    1. Prednisone

    2. Surgical debridement and drainage

    3. Vancomycin plus piperacillin-tazobactam

  • Which of the following is the most appropriate initial treatment?

    1. Intra-articular methylprednisolone

    2. Prednisone

    3. Surgical debridement and drainage

    4. Vancomycin plus piperacillin-tazobactam

      1. Bacterial infectious arthritis and gout can occur concomitantly in the same joint and should be suspected when there is a very high (>50,000/µL) synovial fluid leukocyte count


      2. Patient requires empiric antibiotics, pending the results of synovial fluid culture

      3. It’s possible to have gout and septic arthritis at the same time (though not common)

        • High suspicion given high synovial fluid WBC count

        • Septic arthritis usually presents with an acute monoarthritis

        • A negative gram stain doesn’t rule out an infectious process

        • Given the history of DM, the patient is susceptible for Gram (+), Gram (-) and anaerobic organisms

          • Broad spectrum coverage


        • Intra-articular methylprednisolone would be okay if this was just acute gout, however glucocorticoids should never be injected into a potentially infected joint

        • Prednisone would be a good option if polyarticular gout, however given the risk of infection in this patient, it would not be justifiable until infection is ruled out

        • Patient is having an acute gout flare 

          • “crystal proven”

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