A 59 year old man is seen today because of left knee swelling for which he was seen in the emergency room last night. He has recurrent swelling in his big toes as well as his ankles and left knee in the past 7 years. These episodes are abrupt in onset coming usually in the middle of the night with severe pain that gets very painful within 24 hours. The first episode he had involved his right big toe that became red, hot, and even sheets touching his swollen joint caused severe pain. Occasionally there is back pain associated with these flare-ups. These flare-ups usually resolve within one 2-7 days. After the swelling resolve, there is exfoliation of skin over the involved joint. There are no pain between the flare-ups.

Today he presents with swelling of the left knee and is on crutches. He reports feeling feverish for the past 24 hours. He was seen in the ER last night because the usual medications that he uses for his flare-ups did not seem to help as before. His last attack was six months ago. He does admit to eating a lot of shrimp 3 days ago. He is diabetic, with history of hypertension both poorly controlled, obesity, and has a long standing history of psoriasis.

His temperature last night in the ER was 101. His WBC count was over 16,000. Uric acid level was only slightly elevated at 7.1. His ESR was 55 and CRP was 60. His knee X-rays were normal. He says they did not aspirate his knee last night because they said previous aspirations all had the same results. He says he can not bear weight on his knee today.

Examination shows significant swelling of the left knee with redness and increase warmth and very limited range of motion. He has psoriasis on exam with significant dryness of skin, scaling on his legs, and fissuring of his toes with cracked heels.

At this time you should:

  1. Aspirate and inject the left knee with steroids.
  2. Start taking Indocin 50 mg every 8 hours
  3. Aspirate the left knee, remove all the fluid, and admit patient to the hospital for empiric antibiotic therapy pending culture.
  4. Start Prednisone 60 mg daily for five days.