A 52-year-old man with acute toe pain, swollen red MTP joint, fever; WBC elevated; uric acid 5.9; which is the most likely diagnosis?

• A. Gouty arthritis
• B. Pseudorheumatoid arthritis
• C. Rheumatoid arthritis
• D. Septic arthritis

Answer: (A)

Acute gouty arthritis is the most likely diagnosis. Sudden, severe pain with redness and swelling in the first toe joint (podagra) is the classic presentation of a gout flare. Fever and leukocytosis can accompany the inflammatory response during gout, so these findings don’t rule it out. Importantly, uric acid level during an acute attack can be normal or low, so a normal value does not exclude gout. Distinguishing from septic arthritis is crucial because septic arthritis can also cause fever and a swollen joint, but gout is the classic monoarticular podagra pattern, while rheumatoid arthritis tends to be a chronic, symmetric polyarthritis and pseudogout more commonly affects other joints such as the knee. Definitive diagnosis would come from synovial fluid analysis showing monosodium urate crystals in gout (often needle-shaped and negatively birefringent) with inflammatory fluid, and synovial fluid culture would be used to rule out septic arthritis if there’s concern.