Master the board step 3

Rheumatology
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Uricase (rasburicase and pegloticase) are benign drugs to break down uric
acid. Use if allopurinol or febuxostat is not enough.
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Probenecid and sulfinpyrazone are rarely used for gout any longer. They
increase urinary excretion of uric acid, which is contraindicated in those
with renal insufficiency.
CCS Tip: Do not add probenecid and sulfinpyrazone for gout. They will never be
the correct answer.
Calcium Pyrophosphate Deposition Disease
(Pseudogout)
In pseudogout, the knee and wrist are involved but not the toes. Pseudogout is
much slower in onset than gout, and the patient will not wake up with severe pain.
CCS Tip: In a case of pseudogout, expect hemochromatosis, hyperparathyroidism,
acromegaly, or hypothyroidism in the history.
Diagnostic Testing
Tap the joint and look for positively birefringent rhomboid-shaped crystals.
Treatment
NSAIDS are the best initial therapy. Colchicine is used but is not as effective.
Acute management is the same as gout: NSAIDs or steroids.
Septic Arthritis
The more abnormal the joint, the more likely a patient is to have septic arthritis:
prosthetic joint > rheumatoid arthritis > osteoarthritis > normal joint.
Septic arthritis presents with a swollen, red, immobile, tender joint.
Any arthritic joint or
prosthetic joint is a risk
factor for septic arthritis.
The etiology is as follows:
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Staphylococcus aureus (40 percent)
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Streptococcus (30 percent)
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Gram-negative bacilli (20 percent)
CCS Tip: Call an orthopedic surgery consult when you suspect a septic joint.
The consultation won’t offer much on the CCS, but it needs to be done.
Disseminated gonorrhea is
diagnosed by culture of:
• Joint fluid (50 percent
positive)
• Pharynx (10–20 percent
positive)
• Rectum (10–20 percent
positive)
• Urethra (10–20 percent
positive)
• Cervix (20–30 percent
positive)
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