A 36-Year-Old Man Comes to the Emergency Department Due to Acute

question 184

Multiple Choice

A 36-year-old man comes to the emergency department due to acute pain in his left foot.  He was previously feeling well but suddenly woke from sleep with severe pain at the base of his great toe.  The patient has type 1 diabetes mellitus complicated by peripheral sensory neuropathy and proliferative retinopathy.  He also has end-stage renal disease due to diabetic nephropathy, for which he underwent cadaveric renal transplant 18 months ago.  The patient's diabetes is controlled by an insulin pump.  His other medications include lisinopril, amlodipine, cyclosporine, mycophenolate, and prednisone (5 mg/day) .  Temperature is 37.3 C (99.1 F) , blood pressure is 126/84 mm Hg, and pulse is 88/min.  Physical examination shows an erythematous, swollen, warm, and tender left first metatarsophalangeal joint.  Range of motion testing is limited by severe pain.  There is a moderate hammertoe deformity at the third toe but no abnormal calluses.  Posterior tibial and dorsalis pedis pulses are easily palpable.  Bedside capillary glucose is 184 mg/dL.
Aspiration of the affected joint is likely to reveal which of the following in this patient?

• A)Acid-fast bacilli
• B)Gram-negative diplococci
• C)Gram-positive cocci in clusters
• D)Negatively birefringent, needle-shaped crystals
• E)Positively birefringent, rhomboid crystals

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