Management In A 40 Year Old Man With Acute Pain In the Ankle

A 40-year-old man complains of exquisite pain and tenderness in the left ankle. There is no history of trauma. The patient is taking hydrochlorothiazide for hypertension.
On examination, the ankle is very swollen and tender. There are no other physical examination abnormalities.
Which of the following is the best next step in management?

a. Begin colchicine and broad-spectrum antibiotics.
b. Perform arthrocentesis.
c. Begin allopurinol if uric acid level is elevated.
d. Obtain ankle x-ray to rule out fracture.
e. Apply a splint or removable cast.

Answer And Discussion:


The answer is b. (Perform arthrocentesis.)

The sudden onset and severity of this monoarticular arthritis suggests acute gouty arthritis, especially in a patient on diuretic therapy. However, an arthrocentesis is indicated in the first episode to document gout by demonstrating needle-shaped, negatively birefringent crystals and to rule out other diagnoses such as infection. The level of serum uric acid during an episode of acute gouty arthritis may actually fall. Therefore, a normal serum uric acid does not exclude a diagnosis of gout. For most patients with acute gout, NSAIDs are the treatment of choice. Colchicine is also effective but causes nausea and diarrhea. Antibiotics should not be started for suspected septic arthritis before an arthrocentesis is performed.

Treatment for hyperuricemia should not be initiated in the setting of an acute attack of gouty arthritis. Long-term goals of management are to control hyperuricemia, prevent further attacks, and prevent joint damage. Long-term prophylaxis with allopurinol is considered for repeated attacks of acute arthritis, urolithiasis, or formation of tophaceous deposits. X-ray of the ankle would likely be inconclusive in this patient with no trauma history.

In the absence of trauma, there is no indication for immobilization