A 36-year-old man comes to the emergency department due to acute pain in his left foot. He was previously feeling well but suddenly woke from sleep with severe pain at the base of his great toe. The patient has type 1 diabetes mellitus complicated by peripheral sensory neuropathy and proliferative retinopathy. He also has end-stage renal disease due to diabetic nephropathy, for which he underwent cadaveric renal transplant 18 months ago. The patient's diabetes is controlled by an insulin pump. His other medications include lisinopril, amlodipine, cyclosporine, mycophenolate, and prednisone (5 mg/day). Temperature is 37.3 C (99.1 F), blood pressure is 126/84 mm Hg, and pulse is 88/min. Physical examination shows an erythematous, swollen, warm, and tender left first metatarsophalangeal joint. Range of motion testing is limited by severe pain. There is a moderate hammertoe deformity at the third toe but no abnormal calluses. Posterior tibial and dorsalis pedis pulses are easily palpable. Bedside capillary glucose is 184 mg/dL.
Aspiration of the affected joint is likely to reveal which of the following in this patient?

Question

A 36-year-old man comes to the emergency department due to acute pain in his left foot.  He was previously feeling well but suddenly woke from sleep with severe pain at the base of his great toe.  The patient has type 1 diabetes mellitus complicated by peripheral sensory neuropathy and proliferative retinopathy.  He also has end-stage renal disease due to diabetic nephropathy, for which he underwent cadaveric renal transplant 18 months ago.  The patient's diabetes is controlled by an insulin pump.  His other medications include lisinopril, amlodipine, cyclosporine, mycophenolate, and prednisone (5 mg/day).  Temperature is 37.3 C (99.1 F), blood pressure is 126/84 mm Hg, and pulse is 88/min.  Physical examination shows an erythematous, swollen, warm, and tender left first metatarsophalangeal joint.  Range of motion testing is limited by severe pain.  There is a moderate hammertoe deformity at the third toe but no abnormal calluses.  Posterior tibial and dorsalis pedis pulses are easily palpable.  Bedside capillary glucose is 184 mg/dL. 
Aspiration of the affected joint is likely to reveal which of the following in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0b0_1c1b_8f63_dfbd009bf217_MD0005_00 This patient has acute monoarticular arthritis involving the first metatarsophalangeal (MTP) joint, consistent with acute gout. Gout attacks typically develop abruptly, often starting overnight or in the early morning, with maximal intensity within 12-24 hours. The first MTP joint is most commonly affected. The risk of gout is increased in patients with chronic kidney disease, although this risk can be decreased by dialysis in patients with end-stage renal disease. In addition, the risk is increased following renal (and other solid organ) transplant in patients taking cyclosporine, which decreases uric acid excretion. The diagnosis can be confirmed on synovial fluid analysis, which shows an inflammatory effusion (2,000-100,000/mm³, neutrophilic predominance) and negatively birefringent, needle-shaped monosodium urate crystals. Serum uric acid levels can be suppressed in a gout attack and should not be used for diagnosis during the acute phase of the disease. (Choice A) Tuberculous and nontuberculous mycobacterial arthritis can be seen in patients on immunosuppressive therapy. However, symptoms typically have an insidious onset. Swelling may be present but erythema and warmth are unusual. (Choices B and C) Disseminated Neisseria gonorrhoeae infection usually presents with migratory polyarthritis, tenosynovitis, and rash, although acute septic monoarthritis can also be seen. Staphylococcus species also cause septic arthritis, and the risk is increased in patients on immunosuppressive therapy. However, septic arthritis usually affects the large joints (eg, knees) rather than the small joints of the hands and feet. It evolves over a few days rather than appearing abruptly, as in this patient. (Choice E) Positively birefringent, rhomboid crystals are seen in calcium pyrophosphate dihydrate deposition disease, also known as pseudogout. This condition presents as acute monoarticular arthritis, but the knee joints are more frequently involved than the MTP joints. Educational objective: The risk of gout is increased following renal transplant in patients taking cyclosporine, which decreases uric acid excretion. The diagnosis is confirmed on synovial fluid analysis, which shows an inflammatory effusion and negatively birefringent, needle-shaped urate crystals.

A 36-Year-Old Man Comes to the Emergency Department Due to Acute