Limits...
Gouty arthritis of the spine in a renal transplant patient: a clinical case report: an unusual presentation of a common disorder.

Dhaese S, Stryckers M, Van Der Meersch H, Terryn W, Van Laecke S - Medicine (Baltimore) (2015)

Bottom Line: The patient did not respond to empiric antibiotic treatment and suffered consecutive attacks of severe wrist and ankle pain in conjunction with a persistent fever.Colchicine treatment dramatically improved the patient's clinical condition.Dual-energy computed tomography is a noninvasive technique of possible benefit in the detection of axial gout when joint fluid aspiration is not deemed safe.

View Article: PubMed Central - PubMed

Affiliation: From the Renal Division, Department of Internal Medicine (SD, MS, HVDM, SVL), Ghent University Hospital, Ghent, and Department of Nephrology and General Internal Medicine, Jan Yperman Hospital (WT), Ypres, Belgium.

ABSTRACT
Axial gout is a well-documented but uncommon manifestation of gout. Its mimicking nature and the impracticality of axial joint aspiration might considerably delay its diagnosis. We report a case in a normouricemic renal transplant recipient, whereby the primary symptom of severe neck pain suggested pyogenic spondylodiscitis as an initial tentative diagnosis. Clinical findings included a high C-reactive protein concentration and elevated body temperature. The patient did not respond to empiric antibiotic treatment and suffered consecutive attacks of severe wrist and ankle pain in conjunction with a persistent fever. Blood and joint cultures were negative, but analysis of aspirated ankle joint fluid revealed monosodium urate crystals. A dual-energy computed tomography scan confirmed the presence of monosodium urate crystals in the costovertebral joints. Colchicine treatment dramatically improved the patient's clinical condition. Axial gout should be considered in transplant recipients with severe neck or back pain, fever, and increased inflammatory parameters with a high likelihood of an infectious etiology, despite the presence of paradoxically normal or even decreased serum urate concentrations. Dual-energy computed tomography is a noninvasive technique of possible benefit in the detection of axial gout when joint fluid aspiration is not deemed safe.

Show MeSH

Related in: MedlinePlus

PET/CT scan showing an increased glucose metabolism on the level of thoracic vertebrae 1 and 2. CT = computed tomography, PET = positron emission tomography.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4554016&req=5

Figure 1: PET/CT scan showing an increased glucose metabolism on the level of thoracic vertebrae 1 and 2. CT = computed tomography, PET = positron emission tomography.

Mentions: Seven days after admission, he suddenly reexperienced severe neck pain. Urgent magnetic resonance imaging (MRI) of the spine disclosed degenerative lesions, consistent with the earlier findings on CT- and radiographic imaging. No signs of spondylodiscitis were visualized, and MRI offered no explanation for his febrile syndrome; MRI of early vertebral osteomyelitis and discitis may, however, show nonspecific lesions.10 We subsequently conducted a positron emission tomography (PET)-CT scan in order to find a focus of infection. The PET-CT scan showed increased glucose metabolism at thoracic vertebrae levels 1 and 2 (Figure 1). These findings on PET-CT caused us to suspect spondylodiscitis, despite the negative MRI imaging. We upgraded the antibiotic treatment to piperacillin/tazobactam and teicoplanin in response to spiking fever with repeated negative blood, urine, and stool cultures. Nevertheless, he developed severe wrist and ankle pain over the following days and remained febrile. During his hospital stay, we did a thorough workup to uncover the focus of his assumed infection. Repeated transthoracic and transesophageal ultrasonography of the heart did not reveal endocarditis. Culture and/or polymerase chain reaction of bronchoalveolar lavage fluid results were negative, including mycobacteria, fungi, and yeasts, and we did not detect galactomannan antigen. Serologic testing for brucella antibodies was negative. Bone marrow puncture showed no abnormalities and Ziehl–Neelsen staining was negative. We did not observe any location of increased glucose metabolism on PET scans, other than the above-mentioned localization. Culture and Ziehl–Neelsen staining of the joint fluid of both wrist and ankle were negative. However, we did confirm the presence of monosodium urate crystals in association with leukocytes (43000/μL and 95% polymorphonuclear), on polarized light microscopy of the ankle joint fluid. Serum uric acid was as low as 1.9 mg/dL (normal range 3.4–7 mg/dL) during the acute phase of his axial and peripheral pain attacks (Figure 2).


Gouty arthritis of the spine in a renal transplant patient: a clinical case report: an unusual presentation of a common disorder.

Dhaese S, Stryckers M, Van Der Meersch H, Terryn W, Van Laecke S - Medicine (Baltimore) (2015)

PET/CT scan showing an increased glucose metabolism on the level of thoracic vertebrae 1 and 2. CT = computed tomography, PET = positron emission tomography.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4554016&req=5

Figure 1: PET/CT scan showing an increased glucose metabolism on the level of thoracic vertebrae 1 and 2. CT = computed tomography, PET = positron emission tomography.
Mentions: Seven days after admission, he suddenly reexperienced severe neck pain. Urgent magnetic resonance imaging (MRI) of the spine disclosed degenerative lesions, consistent with the earlier findings on CT- and radiographic imaging. No signs of spondylodiscitis were visualized, and MRI offered no explanation for his febrile syndrome; MRI of early vertebral osteomyelitis and discitis may, however, show nonspecific lesions.10 We subsequently conducted a positron emission tomography (PET)-CT scan in order to find a focus of infection. The PET-CT scan showed increased glucose metabolism at thoracic vertebrae levels 1 and 2 (Figure 1). These findings on PET-CT caused us to suspect spondylodiscitis, despite the negative MRI imaging. We upgraded the antibiotic treatment to piperacillin/tazobactam and teicoplanin in response to spiking fever with repeated negative blood, urine, and stool cultures. Nevertheless, he developed severe wrist and ankle pain over the following days and remained febrile. During his hospital stay, we did a thorough workup to uncover the focus of his assumed infection. Repeated transthoracic and transesophageal ultrasonography of the heart did not reveal endocarditis. Culture and/or polymerase chain reaction of bronchoalveolar lavage fluid results were negative, including mycobacteria, fungi, and yeasts, and we did not detect galactomannan antigen. Serologic testing for brucella antibodies was negative. Bone marrow puncture showed no abnormalities and Ziehl–Neelsen staining was negative. We did not observe any location of increased glucose metabolism on PET scans, other than the above-mentioned localization. Culture and Ziehl–Neelsen staining of the joint fluid of both wrist and ankle were negative. However, we did confirm the presence of monosodium urate crystals in association with leukocytes (43000/μL and 95% polymorphonuclear), on polarized light microscopy of the ankle joint fluid. Serum uric acid was as low as 1.9 mg/dL (normal range 3.4–7 mg/dL) during the acute phase of his axial and peripheral pain attacks (Figure 2).

Bottom Line: The patient did not respond to empiric antibiotic treatment and suffered consecutive attacks of severe wrist and ankle pain in conjunction with a persistent fever.Colchicine treatment dramatically improved the patient's clinical condition.Dual-energy computed tomography is a noninvasive technique of possible benefit in the detection of axial gout when joint fluid aspiration is not deemed safe.

View Article: PubMed Central - PubMed

Affiliation: From the Renal Division, Department of Internal Medicine (SD, MS, HVDM, SVL), Ghent University Hospital, Ghent, and Department of Nephrology and General Internal Medicine, Jan Yperman Hospital (WT), Ypres, Belgium.

ABSTRACT
Axial gout is a well-documented but uncommon manifestation of gout. Its mimicking nature and the impracticality of axial joint aspiration might considerably delay its diagnosis. We report a case in a normouricemic renal transplant recipient, whereby the primary symptom of severe neck pain suggested pyogenic spondylodiscitis as an initial tentative diagnosis. Clinical findings included a high C-reactive protein concentration and elevated body temperature. The patient did not respond to empiric antibiotic treatment and suffered consecutive attacks of severe wrist and ankle pain in conjunction with a persistent fever. Blood and joint cultures were negative, but analysis of aspirated ankle joint fluid revealed monosodium urate crystals. A dual-energy computed tomography scan confirmed the presence of monosodium urate crystals in the costovertebral joints. Colchicine treatment dramatically improved the patient's clinical condition. Axial gout should be considered in transplant recipients with severe neck or back pain, fever, and increased inflammatory parameters with a high likelihood of an infectious etiology, despite the presence of paradoxically normal or even decreased serum urate concentrations. Dual-energy computed tomography is a noninvasive technique of possible benefit in the detection of axial gout when joint fluid aspiration is not deemed safe.

Show MeSH
Related in: MedlinePlus