Review Question - QID 203293

The clinical presentation is consistent with an acute gout. The most appropriate first line of treatment is NSAIDs such as indomethacin.

Gout is a disorder of nucleic acid metabolism that leads to monosodium urate crystal deposition in the joints. This condition typically presents as mono-articular erythema and warmth. The most common joint involved (75% of cases) is the first metatarsophalangeal joint (known as podagra), though it can also affect the knees, ankles, and wrists and usually spares the hips and shoulders. Long-time sufferers can develop tophi, which results from a chronic foreign-body inflammatory response in the joint.

Eggebeen reports that acute gout most commonly presents as an episode of pain, erythema, and swelling of one or a few joints in the lower extremities. The diagnosis of gout can be confirmed if monosodium urate crystals, which are negatively birefringent, are present in synovial fluid. First-line therapy for an acute gout flair is nonsteroidal anti-inflammatory drugs or corticosteroids. Reduction in modifiable risk factors (e.g., high-purine diet, alcohol use, obesity, diuretic therapy) will reduce the frequency of gout episodes.

Weinfeld et al. discuss their experience over a 7 year period with treatment of hallux metatarsophalangeal arthritis in 439 patients. They found that indications for surgical treatment included pain [not managed medically], footwear problems, and failure of non-operative management.

Figure A demonstrates erythema and swelling of the great toe (also called podagra).
Figure B is a radiograph demonstrating joint space narrowing, soft tissue swelling, and radio-densities consistent with gout.
Figure C shows intracellular crystals that are thin, tapered, needle shaped, and strongly negatively birefringent, all consistent with gout.
Illustration A demonstrates a tophus of the elbow in a patient with chronic gout.

Incorrect Answers:
Answer 1: Allopurinol is a urate-lower drug used as preventative therapy but is not introduced for acute gout.
Answer 2: Colchicine is another second-line therapy. It is also used in combination with urate-lowering therapy for chronic gout, and as prophylactic therapy with low-dose colchicine for three to six months may reduce flare-ups.
Answer 4: The joint aspiration is diagnostic of gout and not infection so antibiotics are not indicated.
Answer 4&5: Surgical irrigation and debridement is not indicated in acute presentation of gout.