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Endgames Case Review

An acutely painful hot swollen knee

BMJ 2022; 379 doi: (Published 27 October 2022) Cite this as: BMJ 2022;379:e070231
  1. Jennie Han, internal medicine trainee1,
  2. Sarah Dyball, specialty registrar in rheumatology2,
  3. Anintitha Boon-Itt, specialty registrar in radiology2,
  4. Mark Taylor, consultant in geriatric medicine2
  1. 1Imperial College Healthcare NHS Trust, London W2 1NY, UK
  2. 2Royal Lancaster Infirmary, Lancaster LA1 4RP, UK
  1. Correspondence to: J Han jennie.han{at}

A woman in her 90s presented to the emergency department with shortness of breath, fever, and pulmonary oedema, and was admitted for treatment of community acquired pneumonia and heart failure syndrome with doxycycline, furosemide, and oxygen. She had a medical history of respiratory infections, knee osteoarthritis, and gout (for which she was taking allopurinol). She had no joint replacements.

Two days later, her temperature spiked at 38.3°C on the ward. Examination revealed an acutely warm, tender, and swollen left knee with moderately limited flexion and extension and an effusion. No trauma had occurred on the ward. She was otherwise systemically well. Blood tests showed raised inflammatory markers compared with admission (table 1), but normal renal and liver function, and no derangement of electrolytes. Table 1 also shows the results of the microbiological investigation of the 25 mL of yellow, viscous fluid removed by diagnostic joint aspiration and blood culture.

View this table:
Table 1

Relevant laboratory investigations

A …

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