1. A rare case of tophaceous gout in spine
Mohamed, Noha MD, Deshmukh, Bhakti MD, Patel, Leeza MD, Gizinski, Alison MD
University of Arkansas for Medical Sciences
Introduction
Hospital Course
Gout is a common metabolic disease and is characterized by episodic acute and chronic arthritis caused by the deposition of monosodium urate (MSU) crystals in joints and connective tissues.
It mostly involves joints of the appendicular skeleton, first metatarsal joint being the most common.
Involvement of the axial skeleton is uncommon and deposition of urate crystals in spine is rare. Axial gout has been reported to affect all segments of the spine.
The clinical presentations of gout of the spine can range from back pain to quadriplegia. Radiographic findings can mimic spinal metastases, spinal stenosis and infection on imaging studies.
We report an unusual case of lumbar and cervical spinal canal stenosis caused by tophaceous deposits with no previous history of gout.
Neurosurgery was initially consulted with a possible diagnosis of discitis/osteomyelitis and L2- pelvis posterior lumbar decompression and biopsy was performed.
During the hospitalization, patient later developed posterior inferior cerebellar stroke and right parietal stroke for which neurosurgery performed hemicraniectomy and VP shunt.
Two days after surgery she developed torticollis of her neck, rheumatology was consulted to evaluate the cause of patient’s neck pain.
Bone biopsy L4-L5 showed tophi and fibrous cartilage with degenerative fragments.
Fungal/AFB/Anaerobe/aerobe culture from intervertebral L4-L5 were negative. A B
Erosive changes noted involving the endplates of L4 and
superior endplate of L5 vertebra body
Case Presentation
HPI
70 year old white female with PMH of hypertension, diabetes with neuropathy, chronic renal failure stage 3 was admitted for progressive worsening of low back pain for 3 months
Pain was severe, continuous, dull aching radiating to right thigh
associated with weakness and tingling of right lower extremity
Physical examination
Neck: Restricted ROM due to pain. Tenderness to palpation of cervical spine
Musculoskeletal: Generalized tenderness to palpation of her hands and feet bilaterally. Firm swelling at the DIP of the Right index finger and PIP joint. Joint exam limited due to edema. Tenderness on palpation of lumbar spine
Neurological: Generalized decrease in muscle strength in upper and lower extremities bilaterally 4/5. Negative Straight Leg Raising test.
Laboratory Data
Blood culture and urine culture were negative
A. High-power examination with narrow diaphragm highlights the needle-shaped spaces of dissolved uric acid crystals (arrows).
B. Immunohistochemistry for CD68 shows the histiocytes (arrows), including the multinucleated giant cells (arrowhead) to be positive.
MRI Cervical spine-Severe degenerative changes within the cervical spine from C3 to C6. Moderate to severe canal stenosis at multiple levels with severe neural foraminal narrowing.
Discussion
Spinal gout is often reported because of mechanical consequences of spinal cord compression and the disease remains unsuspected until surgery is performed.
Spinal gout in our case highlights the importance of keeping gout in the differential diagnosis of back pain, especially in patients who have evidence of peripheral arthritis and have risk factors of gout. Na
138 K
3.8 Ca
7.7
Ur acid
7.6
ESR 96
CRP
129
8.2
12.7
237
25.5
References
1. Barrett K1, Miller ML, Wilson JT. Tophaceous gout of the spine mimicking epidural infection: case report and review of the literature 2001;48:1170–1172.
2. Konatalapalli RM, Demarco PJ, Jelinek JS, et al. Gout in the axial skeleton. J Rheumatol 2009;36:609–613.
3. Resnick D, Niwayama G. Monosodium urate crystal deposition disease (gout). In: Resnick D, ed. Bone and Joint Imaging. Philadelphia: WB Saunders Co, 1989;461– 476
Radiograph Rt hand -Deformity of the soft tissues in the distal interphalangeal joint of the thumb and the index finger noted