sunny2
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John Jani Johnson a 70-year-old male with a history of hypertension, peptic ulcer disease, chronic renal insufficiency, and diabetes presents with an acutely swollen and painful left knee. Vital signs and general physical examination are unremarkable, but the left knee has an obvious effusion and is warm, swollen, and red. Arthrocentesis reveals a white blood cell count of 50,000/L, a negative Gram stain, and strongly birefringent needle-shaped intracellular crystals . Which of the following statements concerning this situation is correct?
A. The serum uric acid level will be elevated.
B. Intraarticular glucocorticoid may be given now.
C. Antibiotics are required.
D. A 24-h urine collection will reveal a high level of uric acid.
E. Allopurinol should be given now.
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| robin082006
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B
Pseudogout?
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| saadtazjam
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i agree its pseudogout.However Steroids can be used i dont know about that?any explanation guys?
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| brucella2007
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well needle shaped cystals are gout but they r negatively bireferingent.
positively bireferingent crystals are got but they are rhomboid. here its bireferingent and needle shaped?
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| chemamr
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exactly brucella, that was my first thought when i read the question, i´m confused. Anyhow, if this were a question, i´d choose B. no need to be painful for the patient.
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| chemamr
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you know what i think sunny made a mistake. it should say: "negative Gram stain, and strongly NEGATIVE birefringent needle-shaped intracellular crystals . Which of the following statements concerning this situation is correct? "
the answer still would be B.(intraarticular steroids such as triamcinolone) Why saadtazjam? because the pt has Peptic ulcer dz so can´t take NSAIDs.
comment: A could also be correct. Serum uric acid can be elevated in 25% of pts if you take it once, but if you take it several times (serial), the likelikhood increases to >90%.
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| study_ing
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it is gout i gues..this is what harrison's says..
During acute gouty attacks, strongly birefringent needleshaped MSU crystals with negative elongation are largely intracellular
E, C and A wud not be the answers.m
E is never donein an acute attack. C wud be less likely as this is crystalinduced arthiritis. A is not defenitive, esp in acute attack.
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| study_ing
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- Serum uric acid levels can be normal or low at the time of the acute attack.
- A 24-h urine collection for uric acid is valuable in assessing the risk of stones, in elucidating overproduction or underexcretion of uric acid, and in decidingwhich hypouricemic regimen to use
- uric acid excretion<800 mg per 24 hours--> give uricosuric otherwise give allopurinol.
- however in this patient, the acute treatment takes precedence, adn i wud go for B too.
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| sunny2
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Yes, this is monosodium urate gout (diagnosed on the basis of the presence of urate, birefringent needle-shaped intracellular crystals ) usualy afects one joint initially, especially the great toe. Although abnormalities of uric acid metabolism (high serum or urinary levels) are often seen at some point, many patients present with normal or low serum uric acid. Teatment typically consists of NSAID or colchicine, but these agents are relatively contraindicted in this patient because of the comorbid conditions. Steroid injection is a simple and highly effective alternative.
Urate-lowering drugs should not be initiated during acute attacks.
 , have a nice day !...will try to login again with another simple question 
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