A 48-year-old man presents with sudden-onset severe pain, swelling, and redness in his right big toe. The pain started overnight and intensified by morning, making it difficult for him to walk. He has a history of hypertension managed with hydrochlorothiazide. On examination, the toe joint is warm, erythematous, and tender to touch. Laboratory investigations reveal hyperuricemia and synovial fluid analysis shows needle-shaped, negatively birefringent crystals.
Which of the following is true about his condition?
A. Usually affects young females
B. Usually affects middle-aged males
C. Allopurinol is the best treatment for acute attack
D. Colchicine is effective in prevention of attacks
E. Thiazide diuretic is an effective treatment
Correct Answer: B. Usually affects middle-aged males
Detailed Explanation:
Acute gout, a form of inflammatory arthritis, is most common in middle-aged males, due to higher levels of uric acid compared to females before menopause. It is triggered by monosodium urate crystal deposition in joints. This patient’s presentation aligns with gout: sudden, severe pain in the first metatarsophalangeal joint (podagra), erythema, warmth, and tenderness.
Key risk factors include:
- Gender and age: Gout is rare in premenopausal women due to estrogen’s uricosuric effects.
- Diuretics: Medications like thiazides contribute to hyperuricemia by reducing renal excretion of uric acid.
- Diet and lifestyle: High purine intake, obesity, and alcohol can exacerbate the condition.
Treatment:
- For acute attacks, the focus is on reducing inflammation with NSAIDs, colchicine, or corticosteroids.
- Allopurinol and urate-lowering therapies are NOT initiated during an acute attack, as they can worsen symptoms by mobilizing urate stores.
- Prevention involves lifestyle modifications and long-term urate-lowering therapy in recurrent cases.
Why Other Options Are Incorrect:
A. Usually affects young females
Gout is uncommon in young females, as estrogen enhances uric acid excretion.
C. Allopurinol is the best treatment for acute attack
Allopurinol is used for long-term prevention, not during acute flares. Starting allopurinol during an attack can worsen symptoms.
D. Colchicine is effective in prevention of attacks
Colchicine is primarily used for acute attacks or to prevent flares during the initiation of urate-lowering therapy but is not the mainstay for long-term prevention.
E. Thiazide diuretic is an effective treatment
Thiazides worsen hyperuricemia and are not suitable for patients with gout. Alternative antihypertensives, such as losartan, are preferred in these cases.