Visual Quiz 3

Figure

A 66 yr old man is referred for evaluation of right foot and ankle swelling. He is two months post-cadaveric renal transplant. Physical exam is remarkable for diffuse soft tissue swelling of the entire right foot extending proximally to the mid-calf. The extremity is warm and exquisitely tender, with evidence of hyperhidrosis. Gentle stroking of the skin produces severe pain. Medications include cyclosporine 200 mg po BID, prednisone 20 mg QD, and azathioprine 150 mg CD. Cyclosporine trough level is 274 ng/mL. Laboratory studies reveal: Serum uric acid = 8.61 mg/dL Creatinine = 1.30 mg/dL Radiographs of the foot and ankle reveal areas of patchy demineralization. Technetium-99m pertechnetate bone scintigraphy demonstrates marked increased uptake of radiotracer in the right ankle and entire foot. Aspiration of the right ankle was unsuccessful. In addition to referring the patient to physical therapy, which one of the following options would you recommend?

A. Increase prednisone dose to 20 mg twice daily

B. Begin colchicine 0.6 mg po q hour until pain and swelling resolve, maximum 4.8 mg/24 hours

C. Decrease cyclosporins to 100 mg po twice daily

D. Decrease azathioprine to 75 mg po daily

E. Intraarticular ankle injection of methylprednisolone

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