Aashi
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A 40-year-old man comes to the office because of pain in his right knee for the past three days. The patient denies fever, vomiting, or dysuria. He has no history of trauma but admits to prior episodes of pain, especially after binge drinking. It usually occurs in the knee, ankle, or big toe and is relieved somewhat by ibuprofen. He takes no medications and has no allergies. He has a 25-pack-year smoking history and drinks about half a case of beer when hanging out with friends. His mother developed the same symptoms at the age of 50. On examination, the right knee appears swollen, red, and tender to palpation and has a limited range of motion. You decide to aspirate the knee joint. Which of the following is most consistent with his diagnosis?
(A) Positively birefringent, rhomboid-shaped crystals and 200 white cells/μL
(B) Bipyramidal crystals and 2,000 white cells/mL
(C) Negatively birefringent, rhomboid-shaped crystals and 20,000 white cells/μL
(D) Cloudy and watery fluid with weakly positive birefringent crystals and 20,000 white cells/μL
(E) Watery fluid with strongly negative birefringent crystals and 20,000 white cells/μL
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| prathapdoctor
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D.
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| doc_clotaire
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Seems like Gout
E
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| CocaCola
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I have no idea whether this is psuedogout or gout... however with 20,000/mm3 WBC i would think the aspirate would not be clear...
My guess... D
???
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| s2006
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mono sodium urate,so negatively birefringent crystals. answer is E
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| robin082006
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E
this is Gout
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| Aashi
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Answer:
(E) Watery fluid with strongly negative birefringent crystals and 20,000 white cells/μL
Explanation:
Gout is a metabolic disease that most often occurs in men at middle age or older. It rarely occurs in women until they are postmenopausal. The acute gouty episode typically happens at night and is brought on by excessive alcohol use, trauma, surgery, dietary excess, or glucocorticoid withdrawal. The joint fluid aspirate appears cloudy because of the numerous white cells. They typically range in number from 5,000 to 50,000/μL. The cell count in this range can be found in any kind of inflammatory arthritis, such as gout, pseudogout, or rheumatoid arthritis. Crystal analysis is required to distinguish them. Gout will have negatively birefringent, needle-shaped crystals, whereas pseudogout will have weakly positive, rhomboid-shaped crystals. Rheumatoid arthritis should have no crystals. Septic arthritis from infection usually gives >50,000/μL white cells in the synovial fluid. The inflammatory process causes breakdown of hyaluronate in the joint fluid and makes it become watery.
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| CocaCola
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Yes but doesn't psudeogout present the same way? I don't understand why it can't be psuedogout?
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| Data297
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Pain get worse when he drinks alcohol (which increases mono sodium urate ). In pseudogout it's deposition Calcium pyrophosphate crystals. Someone else might have a better explanation
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| ts97
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In pseudogout crystals will be positively birefringent - as in choice A
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| DrPak
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How would we tell the difference clinically b/w gout and pseudogout? Doesn't pseudogout also flare up with alcohol and red meat?
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| doc_clotaire
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Guys . I think this question is very CLEVER and TRICKY at the time and from what I understand the main difference here is the joint involvement .
GOUT : Main ACTOR : BIG TOE ( podagra) other joint affected can ce : Knee , ankle , wrist , PIP , DIP
PSEUDOGOUT : MAIN ACTOR : KNEE others : wrist ( carpal tunnel Sd , shoulder ,ankle )
Now , the question writer focus all the chief complain to the KNEE , by doing that they are trying to convice us that it 's PSEUDOGOUT . As you know the main actor is Pseudogout is the KNEE , but I think they give it away when they said that the BIG TOE is also affected . From as far I know the BIG TOE IS NOT USUALLY AFFECTED IN PSEUDOGOUT .
The other give away is Gout is more likely to precipated by alcohol , trauma , surgery and drug than is Pseudogout ( 4 H : Hyperpathyroidism , Hemochromatosis , Hypophosphatasia , Hypomagnesemia )
Guys ,Please always remember what Goljan said about the USMLE GUYS
Those Guys are always tring to trick us , they just sit and laught , having a good time and thinking how to SCREW US UP . So , we have to figure out those TRICKS and PLAY THE GAME SOMETIMES
Good Luck All !
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