Review Question - QID 219597

This patient presents with a history and exam most consistent with tophaceous gout of the hand. Synovial fluid evaluation will most likely reveal monosodium urate crystals, which appear as thin, needle-shaped crystals that are strongly negatively birefringent.

Several types of arthropathies can affect the DIPJ, including gout, psoriatic or rheumatoid arthritis, or septic arthritis. Gout is a systemic disease that is caused by intraarticular deposition of monosodium urate crystals. An acute gout flare often presents as monoarticular arthritis and is associated with hyperuricemia. The diagnosis can be confirmed with synovial aspiration and analysis. The prevalence of gout increases with age and involvement of the hand and wrist is more common in women. The mainstay of treatment is non-surgical management. In the acute setting, nonsteroidal anti-inflammatory medications, potential joint aspiration, and soft tissue rest are the primary methods of treatment. Long-term management involves lifestyle changes and anti-uric agents, such as allopurinol. Surgical management is typically reserved for patients who do not respond to anti-uric medications and have functional limitations secondary to flexion contractures.

Barger et al. published a review article regarding fingertip infections. Finger inflammatory pathways that mimic infection, such as gout, are also discussed. Gout typically involves the DIPJ and can mimic other infectious processes. They emphasize that hand plain films that show arthritic changes with periarticular erosions are suggestive of gout.

Day et al. published a review article on psoriatic arthritis, which shares some clinical findings as gout. Both are associated with elevated uric acid levels, increased inflammatory markers, and a predilection for the DIPJ. However, psoriatic arthritis has distinctive radiographic features secondary to erosive and proliferative bone changes. This results in the classic “pencil in cup” deformity. The authors recommend joint aspiration to rule out crystal arthropathy or infection.

Fitzgerald et al. published a review article on tophaceous gout in the hand and wrist. They highlight the clinical findings, including a painful and swollen joint, which can mimic an acute infection. They report that monosodium urate crystals are seen in 85% of acutely inflamed gouty joints. The authors also recommend that acute tophi that are still in the liquid state can be treated with aspiration followed by medical management and soft tissue rest.

Incorrect answers:
Answer 1: Although septic arthritis and gout have similar clinical scenarios, this patient’s chronic presentation and radiographic findings are more suggestive of gout.
Answer 3: Pseudogout does not typically involve the DIPJ.
Answers 4 and 5: Both of these lab findings are associated with rheumatoid arthritis.