Tophaceous gout of the spine mimicking epidural infection: case report and review of the literature

OBJECTIVE AND IMPORTANCE: Tophaceous gout uncommonly affects the axial skeleton. The clinical presentations of gout of the spine range from back pain to quadriplegia. Gout that presents as back pain and fever may be difficult to distinguish from spinal infection. We present a case of a patient with tophaceous gout of the lumbar spine who was initially diagnosed with and treated for an epidural infection. The clinical and diagnostic features of tophaceous gout of the spine are reviewed. CLINICAL PRESENTATION: A 70-year-old man presented with a 2-day history of fever and back pain. A physical examination revealed that he had flank tenderness and evidence of polyarthritis affecting the elbows, knees, and right first metatarsophalangeal joint. A magnetic resonance imaging scan of the patient's lumbar spine showed an extensive area of abnormal gadolinium enhancement of the paramedian posterior soft tissues from L3 to S1 with an area of focal enhancement extending into the right L4-L5 facet joint. INTERVENTION: A laminectomy was performed at L4-L5, and a chalky white material in the facet joint was found eroding into the adjacent pars intra-articularis. Light and polarizing microscopy confirmed the presence of gouty tophus. No evidence of infection was found. CONCLUSION: Gouty arthritis of the spine is rare. Thirty-seven previous cases have been reported. When the clinical presentation includes acute back pain and fever, differentiation of spinal gout from spinal infection may be difficult. The clinical suspicion of spinal gout may lead to the correct diagnosis by a less invasive approach than exploration and laminectomy.     

Thoracic spinal cord compression by a tophus

We report a case of thoracic (T10) spinal cord compression by a tophus in a patient with known chronic gout. Spastic paraplegia developed gradually over 6 months in this 43-year-old man with hypertension, alcohol abuse, and chronic gouty arthritis with tophi. Magnetic resonance imaging and computed tomography visualized an intradural nodule measuring 1.5 cm in diameter at the level of T10, as well as geodes in the left T10 lamina and left T9–T10 articular processes. The nodule was removed surgically and shown by histological examination to be a tophus. The neurological impairments resolved rapidly and completely. We found about 60 similar cases in the literature. Spinal cord compression in a patient with chronic gout can be caused by a tophus.     

Predictive factors of tumour necrosis inhibitor treatment persistence for rheumatoid arthritis: An observational study in 8052 patients

ObjectivesTo determine whether changes in ultrasonography (US) features of monosodium urate crystal deposition is associated with the number of gouty flares after stopping gout flare prophylaxis.MethodsWe performed a 1-year multicentre prospective study including patients with proven gout and US features of gout. The first phase of the study was a 6-month US follow-up after starting urate-lowering therapy (ULT) with gout flare prophylaxis. After 6 months of ULT, gout flare prophylaxis was stopped, followed by a clinical follow-up (M6 to 12) and ULT was maintained. Outcomes were the proportion of relapsing patients between M6 and M12 according to changes of US features of gout and determining a threshold decrease in tophus size according to the probability of relapse.ResultsWe included 79 gouty patients (mean [± SD] age 61.8 ± 14 years, 91% males, median disease duration 4 [IQR 1.5; 10] years). Among the 49 completers at M12, 23 (47%) experienced relapse. Decrease in tophus size ≥ 50% at M6 was more frequent without than with relapse (54% vs. 26%, P = 0.049). On ROC curve analysis, a threshold decrease of 50.8% in tophus size had the best sensitivity/specificity ratio to predict relapse. Probability of relapse was increased for patients with a decrease in tophus size <50% between M0 and M6 (OR 3.35 [95% confidence interval 0.98; 11.44]).ConclusionA high reduction in US tophus size is associated with low probability of relapse after stopping gout prophylaxis. US follow-up may be useful for managing ULT and gout flare prophylaxis.     

UltraSound evaluation in follow-up of urate-lowering therapy in gout phase 2 (USEFUL-2): Duration of flare prophylaxis

ObjectivesTo determine whether changes in ultrasonography (US) features of monosodium urate crystal deposition is associated with the number of gouty flares after stopping gout flare prophylaxis.MethodsWe performed a 1-year multicentre prospective study including patients with proven gout and US features of gout. The first phase of the study was a 6-month US follow-up after starting urate-lowering therapy (ULT) with gout flare prophylaxis. After 6 months of ULT, gout flare prophylaxis was stopped, followed by a clinical follow-up (M6 to 12) and ULT was maintained. Outcomes were the proportion of relapsing patients between M6 and M12 according to changes of US features of gout and determining a threshold decrease in tophus size according to the probability of relapse.ResultsWe included 79 gouty patients [mean (± SD) age 61.8 ± 14 years, 91% males, median disease duration 4 (IQR 1.5;10) years]. Among the 49 completers at M12, 23 (47%) experienced relapse. Decrease in tophus size ≥ 50% at M6 was more frequent without than with relapse (54% vs. 26%, P = 0.049). On ROC curve analysis, a threshold decrease of 50.8% in tophus size had the best sensitivity/specificity ratio to predict relapse [AUC 0.649 (95% confidence interval 0.488; 0.809)]. Probability of relapse was increased for patients with a decrease in tophus size < 50% between M0 and M6 [OR 3.35 (95% confidence interval 0.98; 11.44)].ConclusionA high reduction in US tophus size is associated with lower probability of relapse after stopping gout prophylaxis. US follow-up may be useful for managing ULT and gout flare prophylaxis.     

When gout involves the spine: Five patients including two inaugural cases

Spinal involvement is uncommon during gout and may raise diagnostic challenges. We describe five cases seen at a single center.MethodsWe retrospectively reviewed the medical charts of the five patients with spinal gout seen over a 3-year period.ResultsThere were four men and one woman with an age range of 52 to 87 years. One patient presented with acute neck pain and visualization by imaging studies of a discovertebral tophus, another had febrile arthritis of a lumbar facet joint, and a third presented with a synovial cyst in a lumbar facet joint. The remaining two patients had acute febrile discitis confirmed by magnetic resonance imaging, at the cervical spine and lumbar spine, respectively. Laboratory tests showed systemic inflammation in four patients and marked serum uric acid elevation in two patients. Only three patients reported a previous history of peripheral acute gout attacks. Specimens of the spinal lesions were obtained in three patients and consistently showed monosodium urate crystals with tissue inflammation or a tophus. The outcome was rapidly favorable, either with colchicine therapy alone in four patients or after surgical resection of a facet joint cyst (during surgery to stabilize the lumbar spine) in the remaining patient. The patient with neck pain due to a tophus experienced nerve root pain at the acute phase. No other neurological manifestations were recorded.ConclusionThese case reports illustrate the diagnostic challenges raised by spinal involvement due to gout. The spinal lesions can be inaugural, as seen in two of our five patients.     

Gouty Tophi in Sinus Tarsi of Bilateral Feet Mimicking Synovial Sarcoma:A Case Report

Chronic gout is defined as accumulation of monosodium urate crystals in joints, cartilage, tendons, bursae, bone, and soft tissue. The foot is the most common location for acute gout flares, with the first metatarsophalangeal joint being the most frequent site of tophus formation. However, few studies have reported gouty tophus formation in the subtalar joint. Gout has been termed the “great mimicker” because of its tendency to mimic other pathologic conditions, such as pigmented villonodular synovitis and synovial sarcoma. Herein, we present a rare case of chronic tophaceous gout in the sinus tarsi in both feet in a 23-year-old healthy male, with extensive bony erosions mimicking pigmented villonodular synovitis and synovial sarcoma. We discuss the clinical presentation, distinguishing radiologic characteristics, surgical procedures, and outcome regarding this unique presentation.     

Thoracic spinal cord compression by a gouty tophus. Case report. Review of the literature

An unusual case of thoracic spinal cord compression caused by extradural tophaceous deposits is reported in a 59-year-old female with a long-standing history of gout involving the metatarsophalangeal joints. T1 and T2 magnetic resonance images of the spine illustrated an extradural hyperintense signal extending from T2 to T9. A decompressive laminectomy disclosed a white caseum-like material in the extradural space, together with a small organized hematoma. Histologic examination showed areas of amorphous substance containing urate crystals surrounded by inflammatory cells, which was diagnosed as a gouty tophus. The patient made an uneventful recovery after surgery. Fifteen similar cases of the literature are reviewed. Although spinal involvement by gout seems relatively common, a compression of the spinal cord or of the cauda equina in gout patients seems exceptional. The diagnosis should be considered in patients showing a relevant history of gout, but spinal cord compromise may also represent the initial manifestation of the disease.     

Ultrasonography for diagnosing atypical gout. Two case reports

Gout is characterized by the deposition of monosodium urate crystals on the surface of the articular cartilage, within periarticular tissues, and within bone and skin. The diagnosis rests on identification of the crystals in joint fluid or a tophus. However, joint aspiration is not always feasible, and the presentation may be atypical. We describe two cases of chronic gouty arthritis misdiagnosed as psoriatic arthritis. Ultrasonography of the bone and joints disclosed two patterns recently described as highly suggestive of gout, namely, the double-contour appearance of the cartilage and the snowstorm appearance of the synovial membrane. In addition, ultrasonography was useful for guided aspiration of joint fluid or other material containing monosodium urate crystals. Thus, ultrasonography may contribute to improve the diagnosis and treatment of gout.     

Arthritis of the first metatarsophalangeal joint is not always gout: A prospective cohort study in primary care patients

ObjectivesArthritis of the first metatarsophalangeal joint has been considered pathognomonic for gout, but it is unknown how frequently other forms of arthritis occur in this joint. The aims were to determine the validity of the general practitioner's clinical diagnosis using joint fluid analysis as the reference test, the prevalence of other diagnoses than gout, and the signs and symptoms that discriminate between gout and non-gout patients.MethodsThis prospective cohort study comprised primary care patients with monoarthritis of the first metatarsophalangeal joint. After patient recruitment by general practitioners, patients’ characteristics were collected by a rheumatologist. Joint fluid was analyzed for the presence of monosodium urate-crystals. If crystals were absent, patients entered a follow-up period of 6 years, or until a definite diagnosis. If during follow-up crystals were identified, the patient was classified as already having gout at baseline assessment.ResultsOne hundred and fifty-nine primary care patients were included. At baseline the clinical diagnosis was gout in 98%. The positive and negative predictive values of the diagnosis of gout were 0.79 and 0.75, respectively. After follow-up 77% had gout, 8% had another rheumatic disease, and 15% had a transient unspecified monoarthritis. Gout patients had discriminating signs and symptoms from non-gout patients.ConclusionsGout is an important but certainly not an exclusive cause of arthritis of the first metatarsophalangeal joint.     

Gouty Tophi: A Squamous Cell Carcinoma Mimicker?

BACKGROUND: Digital lesions can have a broad differential diagnosis. Squamous cell carcinoma (SCC), the most common digital malignant neoplasm, must be excluded as the cause of persistent digital lesions causing nail dystrophy. OBJECTIVE: To describe a patient with a periungual hyperkeratotic lesion on the left fifth digit which, upon initial dermatopathologic examination, appeared to be a malignancy. However, on further biopsy, the lesion proved to be a gouty tophus. METHODS: Case report and literature review. RESULTS: An 84-year-old white man presented with a hyperkeratotic papule on the lateral proximal nail fold of the left fifth digit, which resulted in nail dystrophy for 1 year. Similar lesions were present on several other digits which did not affect the nail plate. Initial biopsy was consistent with actinic keratosis and was treated with cryotherapy. When the lesion persisted, repeat biopsy was performed, demonstrating fragments of squamous epithelium with focal atypia and an infiltrative growth pattern. SCC could not be excluded and the patient was referred for Mohs micrographic surgery (MMS) consultation. An excisional biopsy was performed and a white chalky material was observed at the base of the defect. Histopathology confirmed a gouty tophus. The patient was referred to his primary care physician and was treated with allopurinol. CONCLUSION: This is the first report of gouty tophus of the periungual region presenting as a hyperkeratotic lesion. Initial clinical diagnosis favored SCC and histologic evidence suggested a possible early SCC. This lesion can be confused with digital squamous cell carcinoma. The presence of pseu- docarcinomatous hyperplasia may complicate accurate diagnosis.     

The Effects of Gout Following total Knee Arthroplasty: A Retrospective Analysis

BackgroundThe prevalence of gout is increasing along with the number of total knee arthroplasties (TKA) performed annually. The purpose of this study was to evaluate the incidence of gout following TKA in patients who had a previous history of gout and to determine if it is associated with an increased rate of postoperative joint complications.MethodsPatients who did and did not have a preoperative diagnosis of gout and underwent a primary TKA were identified from a national database. The gout patients were matched 1:1 to patients who did not have gout and rates of postoperative gout diagnoses within 2 years of surgery were compared. Complication rates at mean 1 and 2 years were then compared for both patient cohorts using multivariable logistic regressions. A total of 17,463 patients with a prior diagnosis of gout were matched with 17,463 controls.ResultsThere were 53.8% of patients who had previous gout and had a recurrence of gout within 2 years versus 3.6% of controls (Odds Ratios [OR]: 30.86). At mean 1-year, patients who had gout were significantly more likely to experience prosthetic joint infections (PJIs) and revision procedures. At mean 2 years, gout patients were at increased risk of prosthetic loosening, PJI, revision, and incision and debridement procedures.ConclusionThis study suggests that patients who had a prior diagnosis of gout are significantly more likely to experience recurrent episodes of gout after TKA. Gout attacks after TKA are associated with an increase in the rate of joint complications.Level of EvidenceLevel III.     

Lumbar radiculopathy secondary to gouty tophi in the filum terminale in a patient without systemic gout: case report

OBJECTIVE AND IMPORTANCE: Gouty arthritis and gouty tophi of the spine are very rare. We present a patient with the clinical manifestations of an intradural tumor and histologically proven gouty deposits in the filum terminale. CLINICAL PRESENTATION: The patient presented with typical symptoms of lumbar radiculopathy and neurogenic claudication. There was no evidence of peripheral gout. INTERVENTION: Imaging studies, including computed tomography and magnetic resonance imaging, demonstrated a 1-cm, round, intradural, calcified lesion at the L3 vertebral level, causing moderate spinal stenosis. The patient underwent a two-level laminectomy and removal of the mass. A pathological examination of the specimen revealed gouty deposits in the region of the filum terminale. CONCLUSION: Spinal involvement in gout is very rare, and intradural gouty deposits have not been previously described. Intradural gout should be considered in the differential diagnosis of intradural masses.     

手腕部痛风的诊断与治疗

目的 探讨手腕部痛风的诊断方法及治疗.方法 对5例术前临床诊断为手腕部痛风的患者行病灶清除和神经、肌腱松解术,其中2例行痛风石切除.切除病变组织常规行病理检查.结果 术后5例患者伤口均Ⅰ期愈合,无感染发生,术后平均随访时间为7个月.病理检查均证实为痛风性关节炎.2例伴有痛风石的患者,术后手指麻木症状好转,活动功能得到明显改善,但半年以后又有复发.3例患者腕部疼痛消除,腕关节活动及握力恢复接近正常,未再次复发.结论 无明显痛风石形成的非典型手腕部痛风的患者,诊断较为困难,有效的治疗方法为手术探查,可早期明确诊断且术后疗效满意.而有明显痛风石形成的患者诊断容易,但术后疗效欠佳.     

The effect of bariatric surgery on gout: a comparative study

BackgroundObesity is a risk factor for the development of gout. An increased incidence of early gouty attacks after bariatric surgery has been reported, but the data is sparse. The effect of weight loss surgery on the behavior of gout beyond the immediate postoperative phase remains unclear. The objective of this study was to evaluate the pre- and postoperative frequency and features of gouty attacks in bariatric surgery patients.MethodsCharts were reviewed to identify patients who had gout before bariatric surgery. Demographic and gout-related parameters were recorded. The comparison group consisted of obese individuals with gout who underwent nonbariatric upper abdominal procedures.ResultsNinety-nine morbidly obese patients who underwent bariatric surgery had gout. The comparison group consisted of 56 patients. The incidence of early gouty attack in the first month after surgery was significantly higher in the bariatric group than the nonbariatric group (17.5% versus 1.8%, P = .003). In the bariatric group, 23.8% of patients had at least one gouty attack during the 12-month period before surgery, which dropped to 8.0% during postoperative months 1–13 (P = .005). There was no significant difference in the number of gouty attacks in the comparison group before and after surgery (18.2% versus 11.1%, P = .33). There was a significant reduction in uric acid levels 13-months after bariatric surgery compared with baseline values (9.1±2.0 versus 5.6±2.5 mg/dL, P = .007).ConclusionThe frequency of early postoperative gout attacks after bariatric surgery is significantly higher than that of patients undergoing other procedures. However, the incidence decreases significantly after the first postoperative month up to 1 year.     

Case report: An epidural cavernous hemangioma mimicking a dumbbell-shaped neuroma

Introduction and importanceSpinal epidural cavernous hemangiomas are a rare occurrence. This particular case is made even more distinctive by the fact that the lesion mimicked a dumbbell-shaped neuroma. Moreover, it had a very unique localization (wholly epidural, at cervical-thoracic -C7-D1- level). The importance of this case is linked not only to its remarkable rarity, but also to the diagnostic avenues explored.The surgery was carried out by Prof. Riccardo Caruso, Head of the Neurosurgical Department of the Military Hospital of Rome and Professor of Neurosurgery of Sapienza University of Rome, assisted by Dr. Luigi Marrocco, Senior Neurosurgeon of the Military Hospital of Rome. Postsurgical recovery was managed by Dr. Venceslao Wierzbicki, Senior Neurosurgeon of the Military Hospital of Rome.Case presentationIn 2020, a 71 year-old man, suffering from intense pain in the left scapular region and in the ulnar area of the left forearm, underwent surgery for the removal of a spinal epidural cavernous hemangioma involving the left C7-D1 foramen. Prior to surgery, the lesion had been misdiagnosed as a neuroma by a radiologist.Clinical discussionIn the Literature there are other, rare cases of hemangiomas partly located in the spinal canal, and partly located intra and extra foramen. In the case here presented, differential diagnosis as well as a potential Schwannoma, suggested by the dumbbell shape of the lesion, should have considered also the possibility of a meningioma. Two teams of radiologists examined the images, the radiologists of our team, Dr. Valentina Martines and Dr. Emanuele Piccione, thanks to a close inspection of the features of the lesion, postulated the extra-dural position. Other aspects of the scans were then analyzed to help guide future diagnosis of similar lesions.ConclusionWith a spinal tumor affecting the foramen, a close examination of the images allows for accurate presurgical differential diagnosis, differentiating between the more frequent neuroma and other rarer tumors, such as a hemangioma.     

Tophaceous gout causing thoracic spinal cord compression: Case report and review of the literature

Objective

To improve neurologists’ awareness of spine gout by showing a rare case of tophaceous gout in thoracic spine and a summary of vertebral gout in order.

Gouty tophus presenting as an anterior cruciate ligament mass in the knee: Case report and brief review of relevant literature

Introduction and importanceTophacious gout presenting at the anterior cruciate ligament (ACL) is extremely rare and difficult to differentiate from other intraarticular pathology. This is mainly due to conventional diagnostic tools, such as MRI, producing ambiguous results versus pigmented villonodular synovitis (PVNS) and ganglion cysts.Case presentationHere we report an individual in their late-20s with a gouty tophus located at the origin of the ACL in the knee. Urate crystals on the articular cartilage in all three compartments was noted as well as on the synovium. On advanced imaging with an MRI, a large mass was seen anteriorly in the notch surrounding the ACL and posterior cruciate ligament (PCL). The tophus was biopsied and excised arthroscopically with excellent results.Clinical discussionAn ACL mass in the knee has a very broad differential diagnosis. MRI imaging alone makes it very difficult to differentiate between PVNS and gout tophi yielding a pre-operative diagnostic challenge. Additionally, we review diagnostic challenges faced by other groups with similar cases, as well as their chosen treatment.ConclusionGouty tophi arising from the origin of the ACL are extremely rare and remain difficult to diagnose due to their ambiguous nature in conventional imaging. In this report, we clearly convey the disparity in the diagnostic protocol for this type of intraarticular pathology. Future research should look to develop a superior protocol for identifying these pathologies to improve diagnostic accuracy.     

The soft-tissue shaving procedure for deformity management of chronic tophaceous gout

Gout is a condition characterized by the deposition of monosodium urate crystals in the joints or soft tissue. A gouty tophus occasionally mimics an infectious or neoplastic process. However, the conventional enucleating procedure might cause complications. In severe cases, skin necrosis and tendon or joint exposure can occur after debridements. In this series, the soft-tissue shaver is used for deformity management of the chronic tophaceous patients and the results are encouraging. From November 2000 to August 2002, 17 patients with chronic tophaceous gout were treated by the shaver technique. Suction and irrigation were performed simultaneously while the shaver was operating, and chalky deposits of sodium urate could be removed efficiently. Skin necrosis was minimized by means of proper incision planning. Also, bedside debridements and wound wet dressing were helpful for improving the outcomes. The families and patients were satisfied with the results. In conclusion, severe chronic tophaceous gout can be a surgical challenge. The soft-tissue shaving technique can be useful for cosmetic debulking of large tophi in patients with advanced chronic tophaceous gouty arthritis.     

痛风性肩关节炎伴痛风石误诊一例并文献复习

痛风性关节炎是由于尿酸结晶沉积于关节腔或关节周围组织引起的炎症反应,累及肩关节少见。本文报告1例患者,男,49岁,主诉右肩疼痛9个月,加重伴活动受限2周。右肩外旋10°,背手达S5水平,MRI示右肩积液及关节内游离体。以右肩关节游离体、滑膜软骨瘤病可能收入院。关节镜探查见大量尿酸结晶沉积于滑膜、软骨及肩袖组织,行游离体取出及关节清理术。术后病理学检查提示滑膜炎性增生伴尿酸结晶沉积。通过文献回顾分析痛风性肩关节炎的临床特点、诊断及治疗方法。痛风性肩关节炎的临床表现主要为肩关节疼痛及活动受限。含钙盐沉积的痛风结石可以在X线和CT上显影;MRI可显示痛风结石,并能够评估关节内其他病变。痛风性肩关节炎临床表现不典型,影像学上无特异性征象,病理诊断是"金标准"。肩关节镜手术既能明确疾病诊断,又能完成治疗,是痛风性肩关节炎可靠的诊疗方法。     

Crystal arthropathy of the lumbar spine: a report of 4 cases

Gout or pseudogout, caused by deposition of crystals, rarely affects the spine. We report 4 cases with gout or pseudogout in the lumbar spine. Two had cauda equina syndrome and another 2 had spinal stenosis. To avoid unnecessary surgery, this should be considered in the differential diagnosis when treating patients with histories of gout or pseudogout for spinal problems.