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A 30-year-old woman with a history of infection with HIV and hepatitis C is admitted for right-knee swelling and pain, a low-grade fever, and cough. The right leg has been getting increasingly painful and swollen over the past few days. She was discharged three weeks ago from a different hospital with a diagnosis of tuberculosis. Her medications after discharge were rifampin, isoniazid, pyrazinamide, ethambutol, Bactrim, and fluoxetine. She does not remember the doses.
Her temperature is 100.2 F, blood pressure is 145/92 mm Hg, and the physical examination is only remarkable for an erythematous, swollen, tender right knee. What is the most likely etiology of this problem?
(A) Isoniazid
(B) Pyrazinamide
© Ethambutol
(D) Interaction between fluoxetine and antituberculosis medications
(E) Rifampin
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yes, B
Painful swelling of joint
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yes,ur right it's B.........................
This patient appears to have developed drug toxicity from pyrazinamide, which has led to gout. Although it would be helpful to obtain a serum level of uric acid, it would be more helpful to obtain an arthrocentesis to look for negatively birefringent, needle-shaped crystals. If the uric-acid level was elevated and there were crystals in the synovial fluid, then the diagnosis would be gout secondary to pyrazinamide toxicity. A lower-extremity Doppler would only be helpful to rule out venous thrombosis, which would most likely be negative in this case, given the low index of suspicion. Serum transaminases would only add information regarding possible medication toxicities but would not aid in the diagnosis of a specific drug as the etiology. All tuberculosis medications can elevate the transaminases. Those patients who develop an asymptomatic hyperuricemia from pyrazinamide do not need to be treated or have the drug stopped. Ethambutol is associated with optic neuritis.
