Rheumatology for the Hospitalist: Gout and Undifferentiated Musculoskeletal Pain

Gout Diagnosis and Management

• 🎯 Gout diagnosis hinges on aspirating joint fluid and identifying needle-shaped, yellow monosodium urate crystals under a polarizing microscope.
• 💡 In acute flares, colchicine is effective if started within 36 hours; NSAIDs are an option if no contraindications exist, and oral steroids (tapered) are also used.
• ⚠️ Avoid short-burst steroid packs; instead, taper steroids based on clinical improvement to prevent rebound flares.
• 🏥 For hospitalized patients, gout flares can be triggered by cardiovascular disease, IV diuresis, or acute kidney injury.
• 📈 Long-term management involves urate-lowering therapy (e.g., allopurinol), ideally started outpatient or closer to discharge, aiming for uric acid levels below 6 mg/dL.

Differentiating Crystalline Arthropathies

• 🔍 Pseudogout (CPPD) presents with rhomboid or rectangular calcium pyrophosphate dihydrate crystals that are positively birefringent under microscopy.
• ⚡ While acute treatments for gout and pseudogout are similar, long-term management differs significantly, with urate-lowering therapy not applicable to CPPD.
• 🩺 For recurrent CPPD flares, colchicine may be used with variable success, but there are no definitive long-term therapies.

Managing Undifferentiated Musculoskeletal Pain

• ❓ In cases of acute, severe proximal muscle pain and weakness post-URI, infection should be the primary consideration, even if initial tests are negative.
• ⏳ Arthritis associated with infection typically resolves within six weeks; if symptoms persist beyond this, other rheumatologic conditions should be investigated.
• 🔬 Normal CK and absence of significant pain in myositis-like presentations suggest a non-myositic cause; ESR and CRP can help assess inflammation.
• 🩺 While ANA testing can be useful for suspected systemic rheumatic diseases (like lupus), it may not be indicated for acute, infection-like presentations without other specific features.
• 🏥 Imaging may be helpful for specific joints or to rule out rarer conditions like bone tumors or infections, especially in cases of severe pain or localized tenderness.

Transition of Care and Follow-up

• 🏠 For first-time gout flares, urate-lowering therapy is often deferred to primary care follow-up, unless specific indications like CKD stage 3 or tophi are present.
• 🩺 Patients with gout should be counseled on lifestyle modifications such as reducing alcohol, high-fructose corn syrup, red meat, and certain shellfish, though these alone may not reach uric acid goals.
• 👩‍⚕️ For persistent or severe undifferentiated musculoskeletal pain, consultation with rheumatology is recommended, especially if symptoms don't resolve within the expected timeframe for infectious causes.