Gout and Pseudogout

A 62-year-old woman from Mumbai with a 10-year history of osteoarthritis of the knees presents with acute onset of severe pain, swelling, and warmth in both knees over 24 hours. She is afebrile. Synovial fluid aspiration from the right knee shows intracellular, positively birefringent, rhomboid-shaped crystals. The fluid is non-inflammatory (WBC 2,000/μL). Serum calcium is 9.2 mg/dL, phosphate is 3.8 mg/dL, and alkaline phosphatase is normal. What is the most likely diagnosis?

A 58-year-old man from Delhi presents with sudden onset of severe pain, swelling, and erythema of the right big toe joint that began 12 hours ago. He denies recent trauma. On examination, the first metatarsophalangeal joint is warm, tender, and swollen. He has a history of hypertension treated with hydrochlorothiazide and mild chronic kidney disease (creatinine 1.8 mg/dL). Synovial fluid analysis shows needle-shaped, negatively birefringent crystals under polarized light microscopy. Which of the following is the most appropriate immediate management?

Which crystal type is pathognomonic for acute pseudogout?

A 58-year-old man from Delhi presents with acute onset severe pain, swelling, and erythema of the right knee joint. The pain began 6 hours ago after a heavy meal with alcohol. On examination, the knee is warm, tender, and has restricted movement. Serum uric acid is 8.2 mg/dL. Synovial fluid analysis shows 45,000 WBC/mm³ (90% neutrophils), negative Gram stain and culture. Polarized light microscopy reveals needle-shaped, negatively birefringent crystals within neutrophils. What is the most likely diagnosis?

A 72-year-old woman from Mumbai with a 10-year history of osteoarthritis presents with acute onset pain, swelling, and warmth in the left wrist and right knee joints over 2 days. She denies recent trauma or fever. Serum uric acid is 5.2 mg/dL (normal). Synovial fluid from the knee shows 8,000 WBC/mm³ (85% neutrophils), negative culture, and rhomboid-shaped crystals that are blue when parallel to the compensator on polarized light microscopy. X-ray of the knee shows chondrocalcinosis. What is the most appropriate initial management?