History

• 50 yo male with hx of gout on intermittent allopurinol, htn, CKD, and mechanical AVR on warfarin presents with one week of pain/swelling over the right third PIP joint
• There is no history of trauma
• Pt denies fevers

Physical Exam

T 98.6  BP 157/98   HR 62  RR 16  Pox 97%

• Right hand third PIP joint marked edema, erythema, warmth, and tenderness to palpation
• Severe pain on ROM of joint

Plain Film Right Hand

• Soft tissue swelling and joint erosions at 3rd PIP joint

Differential Diagnosis

• The differential diagnosis for monoarticular inflammatory arthritis is narrow, principally gout/psuedogout versus infectious arthritis
• It is also possible for both gout and joint infection to co-exist!

Management

• Arthrocentesis of the joint was performed with aspiration of 1 ml frankly purulent material
• Gram stain of aspirate was negative
• Fluid positive for monosodium urate crystals
• The aspirate was unable to be analyzed for cell count due to increased viscosity of fluid
• Hand surgery consulted who admitted patient for I&D and washout of the affected joint

Teaching Points

• A septic joint can develop in a joint affected by gout, and patients are at increased risk for infection due to chronic damage to the joint
• The incidence of concomitant septic joint in patients with a gout flare is estimated to be 1.5-5%
• A monoarticular arthritis in patients with a history of gout cannot be assumed to be an acute gout flare alone!
• Definitive diagnosis requires a positive culture of synovial fluid aspirate

For further reading:

Panicker VN, Turner JK and Chehade MJ. Concomitant Septic Arthritis and Tophaceous Gout of the Knee Managed with Intermittent Closed Joint Irrigation Combined with Negative Pressure Therapy: A Case Study and Literature Review. Open Orthop J 2014; 8: 482-487.