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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.

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Related in: MedlinePlus

DECT images showing costovertebral deposition of monosodium urate crystal deposition (in green) at the level of thoracic vertebrae 1 and 2 (axial projection). DECT = dual-energy computed tomography.
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Figure 3: DECT images showing costovertebral deposition of monosodium urate crystal deposition (in green) at the level of thoracic vertebrae 1 and 2 (axial projection). DECT = dual-energy computed tomography.

Mentions: Despite treatment with broad-spectrum antibiotics, the patient remained febrile with a further CRP increase up to 276.7 mg/L. This caused us to radically change our perspective. We now considered axial gout as an explanation for the sudden-onset axial pain and peripheral arthritis in this patient, as well as his history of gout, the presence of monosodium urate crystals in the ankle joint fluid, and recent interruption of corticosteroids. Reminiscent of this, a DECT scan finally confirmed axial gout (Figure 3) at the costovertebral joints of thoracic vertebrae 1 and 2, consistent with the location on PET/CT scan (Figure 1). Only after we initiated colchicine at a dose of 1 mg daily in 2 separate doses did our patient completely recover; he was discharged in good health with a normalized CRP. We started him on a 150 mg daily dose of prophylactic allupurinol 2 weeks later.


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)

DECT images showing costovertebral deposition of monosodium urate crystal deposition (in green) at the level of thoracic vertebrae 1 and 2 (axial projection). DECT = dual-energy computed tomography.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 3: DECT images showing costovertebral deposition of monosodium urate crystal deposition (in green) at the level of thoracic vertebrae 1 and 2 (axial projection). DECT = dual-energy computed tomography.
Mentions: Despite treatment with broad-spectrum antibiotics, the patient remained febrile with a further CRP increase up to 276.7 mg/L. This caused us to radically change our perspective. We now considered axial gout as an explanation for the sudden-onset axial pain and peripheral arthritis in this patient, as well as his history of gout, the presence of monosodium urate crystals in the ankle joint fluid, and recent interruption of corticosteroids. Reminiscent of this, a DECT scan finally confirmed axial gout (Figure 3) at the costovertebral joints of thoracic vertebrae 1 and 2, consistent with the location on PET/CT scan (Figure 1). Only after we initiated colchicine at a dose of 1 mg daily in 2 separate doses did our patient completely recover; he was discharged in good health with a normalized CRP. We started him on a 150 mg daily dose of prophylactic allupurinol 2 weeks later.

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