Program Director EVMS Norfolk, Virginia, United States
Case Diagnosis: Acute tophaceous gout flare of the knee.
Case Description: A 33-year-old male with intracranial hemorrhage and residual left hemiplegia underwent craniotomy and subsequent ICU admission. Upon admission to inpatient rehabilitation, he reported left knee pain limiting his participation in therapies. He could not provide accurate onset due to altered mentation during his previous admission. Physical exam revealed significant left knee swelling and limited range of motion.
Knee radiograph noted a suprapatellar effusion. An MRI suggested a partial-thickness PCL tear, meniscus tears, and a nondisplaced tibial plateau fracture. Orthopedic consultation advised non-weight bearing and further evaluation. CT imaging, when evaluated in concert with the previous knee MRI, did not support ligamentous injury or tibial plateau fracture, but more closely resembled diffuse tophaceous gout, infiltrating the PCL ligament and surrounding tissue. Ultrasound evaluation, aspiration, and fluid analysis confirmed acute gout flare. He improved with oral prednisone and colchicine, allowing full participation during therapy.
Discussions: This case highlights the importance of a differential diagnosis within clinical context, and the benefit of ultrasound as a diagnostic tool. The patient’s swollen knee indicated an acute problem despite no recent injury, however, this was muddled by poor memory recall of his previous hospitalization and a vague memory of knee injury before admission. Given his age and absence of chronic knee issues, while reporting a subacute left knee injury, ligamentous damage was prominently considered, and gout was overlooked. Nevertheless, ultrasound is an affordable tool for musculoskeletal evaluation, and highly sensitive for identifying gout tophi and erosions within soft tissue.
Early utilization of sonography for joint evaluation and aspiration may have spared the patient multiple consultations, inaccurate diagnoses, and an expensive work-up.
Conclusions: Gout should be considered with acute onset of joint swelling. Ultrasound is a useful tool during inpatient rehabilitation to assess gout pathology and may prevent expensive and unnecessary evaluations.
