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Gout — SCE Rheumatology MCQ

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ModerateCrystal ArthropathiesGoutSCE Rheumatology

A 66-year-old woman with chronic kidney disease presents with her first episode of acute monoarthritis affecting the knee. The joint is hot and swollen, CRP is 164 mg/L and temperature is 37.8°C. She has no previous crystal diagnosis and takes low-dose prednisolone for PMR. What is the most appropriate investigation?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Urgent synovial fluid microscopy, culture and crystal analysis

Explanation lettering: E = shown as A · D = shown as B · A = shown as C · B = shown as D · C = shown as E

Urgent synovial fluid microscopy, culture and crystal analysis is best because first hot swollen joint with inflammatory markers requires aspiration to identify crystals and exclude septic arthritis. B is less suitable because starting allopurinol does not diagnose or treat possible septic arthritis; C is less suitable because delayed MRI is inappropriate for acute monoarthritis; D is less suitable because serum urate alone cannot distinguish gout from sepsis; E is less suitable because anti-CCP does not evaluate acute hot knee. Clinical pearl: crystals do not exclude infection, so culture remains essential.

Reference: NICE NG219; BSR hot swollen joint guideline