How To Evaluate Monoarticular Joint Pain
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?
Intra-articular methylprednisolone
Prednisone
Surgical debridement and drainage
Vancomycin plus piperacillin-tazobactam
Which of the following is the most appropriate initial treatment?
Intra-articular methylprednisolone
Prednisone
Surgical debridement and drainage
Vancomycin plus piperacillin-tazobactam
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
Patient requires empiric antibiotics, pending the results of synovial fluid culture
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”
