MCQs in Rheumatology:
Gout
Contributors: These MCQs were written by Dr Dipti Patel, and Dr Pravin Patil, and
were reviewed by Dr Ed Roddy. The MCQs were edited by Dr A Abhishek who also
facilitated the review process.
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Question 1
You see a 65 year old man in the rheumatology day unit with acute onset pain and
swelling of the right 1st MTP joint. You are satisfied that his history and examination
are consistent with acute gout. His past medical history includes hypertension,
chronic kidney disease stage 4, ischemic heart disease, asthma, peptic ulcer
disease and gout. His regular medications are verapamil, bendroflumethiazide,
simvastatin, ranitidine, theophylline and clopidogrel.
Which of the following is the best option to treat acute gout in this case?
1.
2.
3.
4.
5.
Allopurinol 100 mg O.D.
Ibuprofen 400mg T.D.S.
Febuxostat 40mg O.D.
Colchicine 500mcg B.D.
Prednisolone 15-20mg O.D.
Question 2
A 76 year old gentleman with a history of hypertension, on diuretics, presents to the
rheumatology clinic with a two day history of acutely swollen left knee. Arthrocentesis
is performed, and synovial fluid is stored in the refrigerator for analysis the following
day.
Which of the following problems can arise as a result of delayed analysis of synovial
fluid?
1.
2.
3.
4.
5.
Decrease in leukocyte count
Increase in number of urate crystals
Increase in number of calcium pyrophosphate crystals
Appearance of cholesterol crystals
No problems at all
Question 3
A 50 year old man presents to the rheumatology department with acute onset of
severe pain, redness and swelling of the left 1st metatarso-phalangeal joint. His past
medical history includes hypertension, and cadaveric renal transplant 6 years ago.
His medications include Azathioprine 100mg, cyclosporine 200mg, prednisolone
5mg, verapamil 240mg. A diagnosis of gout is made. His eGFR is 50 ml/min, and the
serum urate is elevated. Other blood tests FBC and LFTs are normal.
Which of the following does not contribute to hyperuricaemia?
1.
2.
3.
4.
5.
Age
Azathioprine
Cyclosporine
Gender
Renal impairment
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Question 4
A 65 year old man with a history of hypertension on bendroflumethiazide, and
amlodipine was referred to the Rheumatology department with recurrent episodes of
acute gout affecting the left 1st MTP joint. The serum uric acid was 0.56 mmol/L, and
he had normal renal function. He was commenced on allopurinol 300mg/day. 6
weeks later he presented with fever and a maculo popular rash. On examination, the
temperature was 380C, pulse was 90 beats/min, BP was 140/90 mmHg. He had
extensive maculopapular rash with target lesions. Systemic examination was normal.
The results of the blood tests were as follows
Hb 12.5 gm/dl
WBC count 15.4 x 103/ml
Neutrophils 62%
Eosionophils 16%
Lymphocytes 22%
Urea-15mmol/L(2.5-7.5)
Creatinine- 300mmol/L(62-120)
ALT 328 IU/L (0-40)
ALP 600 IU/L(30-130)
Biluribin 65mmol/L (0-17).
The urine dipstick, blood culture at 48 hours, chest x ray and ultrasound scan of the
abdomen were normal.
What is the most likely diagnosis?
1.
2.
3.
4.
5.
Acalculous cholecystitis
Acute viral hepatitis
Allopurinol hypersensitivity syndrome
ANCA associated vasculitis
Leptospirosis
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Question 5
A 50 year old man with past medical history of cadaveric renal transplant 12 years
ago and hypertension presents to his GP with an acutely painful, swollen left 1st
Metatarsophalangeal joint. Blood test shows stable renal function and high urate. A
diagnosis of acute gout is made. His current treatment includes Azathioprine 100mg,
cyclosporine 200mg, verapamil 240mg, cocodamol PRN.
Which of the following would be the most appropriate treatment for his acute gout?
1.
2.
3.
4.
5.
Allopurinol after reducing dose of azathioprine by 50-75%
Benzbromarone
Colcichine 500mcgs TDS
Naproxen 500mg BD with PPI cover
Oral or intra-articular steroids
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Answer:
Q1.
5. Prednisolone 15-20mg OD for 5-7 days
Regular use of Ibuprofen is not safe in view of asthma, peptic ulcer disease, renal
impairment, and ischaemic heart disease. Allopurinol and febuxostat are not
indicated for the immediate treatment of acute gout. Also, febuxostat is
contraindicated in ischaemic heart disease, and in patients using azathioprine,
mercaptopurine, or theophylline. Colchicine is likely to accumulate in patients with
renal impairment, and associate with significant side effects, especially diarrhoea.
Q2.
1. Decrease in leukocyte count
If synovial fluid analysis is delayed more than 6 hours, results may be spuriously
altered. Decrease in leukocyte count may occur due to cell disruption. Also crystal
artefacts can appear. Calcium pyrophosphate and urate crystals may also dissolve.
Q3.
2. Azathioprine
Over 90% of patients with gout have diminished renal excretion of uric acid which
may be caused by genetic factors, alcohol, hypertension, obesity and insulin
resistance, impaired renal function, lead poisoning, and numerous drugs including
diuretics (both loops and thiazides), cyclosporine, tacrolimus, nicotinic acid,
ethambutol and pyrazinamide. The remainders are either over-producers of uric acid
or have combined under-excretion and over-production. Important causes of overproduction include excess dietary purine consumption, alcohol (beer in particular is
rich in the purine guanosine), and increased nucleotide turnover in myeloproliferative
and lymphoproliferative disorders. Inherited enzyme abnormalities in uric acid
synthesis which lead to high uric acid levels such as superactivity of
phosphoribosylpyrophosphate synthetase (PRPP)and partial deficiency of
hypoxanthine guanine phosphoribosyltransferase (HGPRT) are very rare.
Azathioprine poses a challenging problem in the management of transplant
recipients who have gout as an important interaction between azathioprine
allopurinol exists risking significant bone marrow suppression. However, azathioprine
is not a cause of hyperuricaemia and gout.
Q4.
3. Allopurinol hypersensitivity syndrome
In most patients, allopurinol is well tolerated. About 2% of treated patients develop a
rash. Also, an estimated 0.4%, people on allopurinol, predominantly those with renal
failure and on thiazides, may experience a severe idiosyncratic reaction known as
allopurinol hypersensitivity syndrome. This is characterised by skin reactions, fever,
eosinophilia, and multiorgan involvement, with a mortality of up to 25% (reference 13). Acalculous cholecystitis is usually associated with gall bladder distention on
ultrasound. Acute viral hepatitis is unlikely to present with co-existent renal
impairment, and leptospirosis is unlikely in the absence of a clear history of exposure
to contaminated water. ANCA associated vasculitis is a reasonable differential, but is
unlikely as the urine dipstick is normal. Diagnostic criteria for allopurinol
hypersensitivity syndrome include
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A clear history of exposure to allopurinol


Lack of exposure to another drug which may have caused a similar clinical
picture
A clinical picture including
o At least two of the following major criteria
 Worsening renal function
 Acute hepatocellular injury
 A rash, including either toxic epidermal necrolysis, erythema
multiforme, or a diffuse maculopapular or exfoliative dermatitis
Or
o
One of the major criteria plus at least one of the following minor criteria
 Fever
 Eosinophilia
 Leukocytosis
1. Singer JZ, Wallace SL The allopurinol hypersensitivity syndrome
unnecessary morbidity and mortality.Arthritis Rheum1986;2982
2. Arellano F, Sacristán JA Allopurinol hypersensitivity syndrome a
review.Ann Pharmacother1993;27337–43
Kumar A, Edward N, White MI, Johnston PW, Catto Allopurinol, erythema
multiforme, and renal insufficiency.BMJ1996;312173–4.
Q5.
5. Oral or intra-articular steroids
NSAIDS are contraindicated with renal insufficiency and concurrent cyclosporine
treatment. Ciclosporin inhibits the metabolism of colchicine and may therefore result
in colchicine related toxicity. Allopurinol and benzbromarone are used in reducing the
risk of acute gout in future, and have no role in the treatment of acute attacks of
gout. Allopurinol and azathioprine may result in severe leucopenia or bone marrow
failure even if the dose of azathioprine is reduced.
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