A 61-year-old man comes to the emergency department because of severe pain in his right knee over the last 12 hours. He also has had malaise and low-grade fever. He has not had any trauma. He has peptic ulcer disease, type 2 diabetes mellitus, hypertension, and chronic renal insufficiency. He was hospitalized one year ago for upper gastrointestinal bleeding that required a blood transfusion. He has smoked one pack of cigarettes daily for 40 years. He describes himself as a "heavy drinker." Temperature is 37.9 C (100.1 F), blood pressure is 152/87 mm Hg, and pulse is 96/min. BMI is 32 kg/m². Examination shows a swollen, warm, and tender right knee. Laboratory results are as follows: Aspiration of the knee joint is performed. Compensated, polarized, light microscopic analysis of the aspirate shows intracellular needle-shaped, negatively birefringent crystals. Gram staining of the synovial fluid shows no bacteria. Which of the following is the most appropriate next step in management?

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Explanation: This patient's presentation is most consistent with an acute gout attack. Gout commonly presents as a mono-articular arthritis in the lower extremity (most commonly in the first metatarsophalangeal joint but also in the knee). High alcohol intake can precipitate a gout attack. This patient's uric acid level is mildly elevated, although this could be an incidental finding and cannot confirm the diagnosis by itself. This patient's borderline fever and elevated leukocyte count can be seen with gout, although septic arthritis should always be a concern and arthrocentesis may be needed to differentiate between the 2 conditions. The presence of negatively birefringent, needle-shaped crystals on the joint aspirate confirms the diagnosis of gout. Non-steroidal anti-inflammatory drugs (NSAIDs) such as indomethacin are the first line treatment for patients with acute gout. However, this patient's chronic renal failure and history of a gastrointestinal bleed are contraindications to NSAID use (Choice D). Colchicineshould also be avoided in renal failure (eg, creatinine 3.9 mg/dL in this patient) (Choice B). Because of the above contraindications, intra-articular corticosteroids are the best option for this patient, especially because there is only one joint involved. Excluding septic arthritis is particularly important if the use of intra-articular corticosteroids is being considered. (Choice A) Allopurinol is a medication that decreases uric acid production. It is used to prevent gout flares but is not typically initiated during acute gout flares. (Choice C) Oral prednisone would be the treatment of choice if this patient had multiple involved joints. Because the patient has a mono-articular arthritis, corticosteroids can easily be injected into the affected joint. Systemic (eg, oral) corticosteroids should be avoided if possible given the patient's history of gastrointestinal bleed and type 2 diabetes mellitus. Educational objective: Nonsteroidal anti-inflammatory drugs and colchicine are the first line treatments for acute gout flares but are contraindicated in patients with renal failure. Instead, corticosteroids should be used in these patients and can be injected locally in patients with a mono-articular arthritis or given orally in patients with multiple joint involvement. References: Current therapy of acute microcrystalline arthritis and the role of corticosteroids. (http://www.ncbi.nlm.nih.gov/pubmed/19078115) Management of acute and chronic gouty arthritis: present state-of-the-art. (http://www.ncbi.nlm.nih.gov/pubmed/15481999)

A 61-Year-Old Man Comes to the Emergency Department Because of Severe