A 51-year-old man without a history of gout presented 4 days after abrupt onset of a painful right elbow without trauma. He had no fevers or constitutional symptoms. He was monogamous and denied drug use. On examination, the patient appeared uncomfortable and resisted right elbow movement. The joint was swollen, erythematous, warm, and tender. Other joints were unaffected. Findings from the rest of his examination were normal. His white blood cell (WBC) count was within reference range (4500-11 000/μL; to convert WBC to ≤109/L, multiply by 0.001), and his serum glucose level was 147 mg/dL (to convert glucose to millimoles per liter, multiply by 0.0555). His uric acid level was not checked. A radiograph of the elbow revealed an effusion without erosions. Arthrocentesis produced straw-colored synovial fluid containing a WBC count of 9696/μL (91% neutrophils), and a glucose level of 133 mg/dL. Initial polarized light microscopy showed no crystal formation; results from Gram stain and bacterial culture were negative.
Lessing JN, Mathias PC, Pierce RG. A Tincture of Time—Latent Crystal Formation and Clinical Decision-Making in Acute GoutA Teachable Moment. JAMA Intern Med. 2016;176(2):165-166. doi:10.1001/jamainternmed.2015.6824