MKSAP Quiz: 4-day history of swelling and severe pain
A 69-year-old man is evaluated for a 4-day history of swelling and severe pain of the dorsum of his hand.
A 69-year-old man is evaluated for a 4-day history of swelling and severe pain of the dorsum of his hand. He has a distant history of gout involving the first toe, midfoot, and ankles. Six days ago, he was bitten by his cat.
Physical examination reveals erythema and warmth of the dorsum of the hand. On musculoskeletal examination, he has decreased flexion and extension of the wrist secondary to swelling and pain.
Aspiration of the wrist joint is performed. The synovial fluid leukocyte count is 23,000/µL (23 × 109/L); polarized light microscopy of synovial fluid reveals extracellular needle-shaped negatively birefringent crystals. Results of synovial fluid Gram stain and cultures are pending.
In addition to updating his tetanus immunization, which of the following is the most appropriate treatment for this patient?
A. Indomethacin
B. Ampicillin–sulbactam
C. Ampicillin–sulbactam; indomethacin
D. Intra-articular corticosteroid injection
MKSAP Answer and Critique
The correct answer is C) Ampicillin–sulbactam; indomethacin. This item is available online to MKSAP 14 subscribers in the Rheumatology section, Item 27.
Antibiotics, such as ampicillin–sulbactam and others with broad-spectrum coverage, are indicated for animal bites. In this setting, infection with Pasteurella multocida, as well as staphylococcal and streptococcal species and anaerobic bacteria, may be present. Evaluation for prophylactic therapy for tetanus and rabies on an individual basis also is indicated.
The presence of synovial fluid leukocytosis with needle-shaped negatively birefringent crystals consistent with monosodium urate crystals indicates acute gouty arthritis. However, in the setting of a cat bite to the area, coexistent infection must be considered. Initiation of treatment for gout in addition to antibiotic therapy for presumed infection is reasonable because of the severity of this patient's symptoms. Appropriate treatment for an acute attack of gout includes short-course therapy with a nonsteroidal anti-inflammatory drug, such as indomethacin; colchicine; or a corticosteroid. This patient's age warrants close monitoring if a high-dose nonsteroidal anti-inflammatory drug is administered.
Intra-articular corticosteroid therapy is not indicated until culture is shown to be negative, because this patient may have infection. Coexistence of acute gouty arthritis and infection is rare but has been reported, even in the absence of trauma.
Key Point
- Antibiotics, such as ampicillin–sulbactam and others with broad-spectrum coverage, are indicated for animal bites.