WBR0751
| Author | [[PageAuthor::Rim Halaby, M.D. [1]]] |
|---|---|
| Exam Type | ExamType::USMLE Step 1 |
| Main Category | MainCategory::Pathology |
| Sub Category | SubCategory::Musculoskeletal/Rheumatology |
| Prompt | [[Prompt::A 48 year old man presents to the emergency department complaining of excruciating left toe pain. On physical examination, the physician notes erythema, edema, and tenderness around the left meta-tarsal-phalangeal joint of the great toe. Lab work-up reveals elevated levels of uric acid. Arthrocentesis of the joint is performed. Fluid analysis shows needle-shaped yellow crystals under parallel light. What is the most likely finding during history-taking consistent with this patient's condition?]] |
| Answer A | AnswerA::Recent intake of beer |
| Answer A Explanation | AnswerAExp::Intake of beer and other alcohols is associated with gouty attacks. |
| Answer B | AnswerB::Personal history of appendicitis |
| Answer B Explanation | AnswerBExp::Appendicitis is not associated with gout. |
| Answer C | AnswerC::Chronic exposure to paint |
| Answer C Explanation | AnswerCExp::Chronic exposure to paint is not associated with gout. |
| Answer D | AnswerD::Recent strenuous exercise |
| Answer D Explanation | AnswerDExp::Exercise may help with decreasing the number of episodes of gouty attacks. |
| Answer E | AnswerE::Recent intake of corticosteroids |
| Answer E Explanation | AnswerEExp::Corticosteroids may be used for relief of gout symptoms. |
| Right Answer | RightAnswer::A |
| Explanation | [[Explanation::The patient is presenting with a gouty attack. Gout is considered the most common inflammatory arthritis in men. It occurs due to deposition of monosodium urate (MSU) crystals and is associated with hyperuricemia (overproduction of urate or underexcretion of urate by the kidneys), with levels above 6.8 mg/dL. Beyond this level, uric acid is not soluble anymore in physiologic condition. Gout has 2 phases: The first phase is characterized by episodic attacks, each lasting 1-2 weeks. The second phase occurs due to untreated initial phase; patients progress to chronic tophaceous gout with polyarticular attacks. While patients are asymptomatic between attacks in the first phase, they are symptomatic between attacks in the second phase.
Alcohol may induce hyperuricemia, which might be used as a marker of alcohol intake. Among alcohol beverages, beer seems to be the most commonly associated alcoholic drink associated with recurrence of gouty attacks, most probably due to its high content of guanosine, which is a highly absorbable purine compared to other nucleosides. Two or more beers per day was associated with a two-fold increase in gout. Educational Objective: Alcohol intake, especially beer, is associated with gout. References: Choi HK, Atkinson K, Karlson EW. et al. Alcohol intake and risk of incident gout in men: a prospective study. The Lancet. 2004; 363:1277-81. Neogi T. Gout. N Engl J Med. 2011; 364:443-452. |
| Approved | Approved::No |
| Keyword | WBRKeyword::beer, WBRKeyword::alcohol, WBRKeyword::gout, WBRKeyword::gouty, WBRKeyword::attack, WBRKeyword::podagra, WBRKeyword::toe, WBRKeyword::great, WBRKeyword::big, WBRKeyword::inflammation, WBRKeyword::erythema, WBRKeyword::swelling, WBRKeyword::edema, WBRKeyword::uric, WBRKeyword::acid |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |