A 48-year-old male presents with acute severe pain, swelling, and redness in his right first metatarsophalangeal joint (podagra). Arthrocentesis reveals needle-shaped, negatively birefringent crystals under polarized light microscopy. What is the first-line medical therapy for this acute presentation?

Answer and explanation

Correct answer: D. Oral nonsteroidal anti-inflammatory drug (indomethacin) or colchicine

  1. Step 1: Needle-shaped negatively birefringent crystals under polarized microscopy are diagnostic of monosodium urate crystals in acute gouty arthritis.
  2. Step 2: First-line management for acute gout flares includes oral NSAIDs, low-dose colchicine, or corticosteroids.
  3. Step 3: Urate-lowering therapy (allopurinol) should not be newly initiated during an acute flare as sudden shifts in serum urate prolong the attack.
Answer
Oral nonsteroidal anti-inflammatory drug (indomethacin) or colchicine.
Why not the others: 'Initiate allopurinol 300 mg daily immediately' can exacerbate the acute flare by mobilizing crystal deposits; 'Intravenous uricase enzyme infusion' is reserved for refractory chronic tophaceous gout; 'Long-term probenecid therapy' is a chronic uricosuric agent, not an acute anti-inflammatory.

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