1/9. Chronic tophaceous gouty arthritis mimicking rheumatoid arthritis.OBJECTIVES: To analyze the factors which differentiate chronic tophaceous arthritis from rheumatoid arthritis. methods: We describe two cases of chronic gouty arthritis masquerading as rheumatoid arthritis. The characteristic features of each of these two conditions and the diagnostic approach are discussed in light of relevant literature. RESULTS: The correct diagnosis was reached by the combination of accurate history taking (family history of gout, alcoholism, previous diuretic therapy and renal stones), guiding clinical features (subcutaneous tophaceous deposits) and specific radiological (assymetrical erosions with sclerotic margins and overlying edges) and laboratory findings (hyperuricemia and hyperuricosuria). It was confirmed by the identification of monosodium urate (MSU) crystals in the synovial and subcutaneous tissues. CONCLUSIONS: gout and rheumatoid arthritis rarely coexist. Chronic gouty arthritis may mimic rheumatoid arthritis, and vice-versa. Clinical suspicion supplemented by characteristic laboratory, radiological and histologic findings help at reaching an accurate diagnosis.- - - - - - - - - - ranking = 1keywords = hyperuricemia (Clic here for more details about this article) |
2/9. Bartter's syndrome with gouty arthritis.A 45-year-old woman with Bartter's syndrome complicated with gouty arthritis is reported. Bartter's syndrome was diagnosed from hypokalemia, metabolic alkalosis, high plasma renin activity, normal blood pressure and attenuated pressor response to exogenous angiotensin ii infusion. serum uric acid was 11.8 mg/dl, the renal clearance of uric acid was low (3.0 ml/min) and fractional excretion of uric acid (FEUA) was 7.0%, being the lower limit of the normal range. Fractional excretion of phosphate was low (5.3%) and fractional free water clearance per fractional distal sodium delivery was 0.51. The mechanism of hyperuricemia in this case is discussed.- - - - - - - - - - ranking = 1keywords = hyperuricemia (Clic here for more details about this article) |
3/9. Medial canthal tophus associated with gout.PURPOSE: To report a case with a gouty tophus at the medial canthus. DESIGN: Observational case report. methods: review of the clinical, laboratory, photographic, and pathologic records of a patient with a gouty tophus at the medial canthus. RESULTS: A 27-year-old man had a 3-year history of gouty arthritis and poorly controlled hyperuricemia. A medial canthal mass without discomfort developed gradually over 3 months. An excisional biopsy was performed, and the tissue was fixed in formalin for pathology. Analysis of a routine hematoxylin-and-eosin-stained section disclosed a multilobulated pseudocyst filled with amorphous eosinophilic material. Further staining with nonaqueous alcoholic eosin and viewed under a polarizing microscope indicated the presence of birefringent urate crystals. CONCLUSIONS: Gouty tophus can develop progressively at the medial canthus, especially in people with uncontrolled hyperuricemia. A formalin-fixed specimen, stained with nonaqueous alcoholic eosin, demonstrates abundant birefringent urate crystals under a polarizing microscope.- - - - - - - - - - ranking = 2keywords = hyperuricemia (Clic here for more details about this article) |
4/9. gout in the heart transplant recipient: physiologic puzzle and therapeutic challenge.PURPOSE: hyperuricemia and gouty arthritis have been associated with cyclosporine use in renal transplant recipients. Patients requiring heart or heart-lung transplantation may have additional risk factors for the development of gout, yet it has not previously been described in this population. We share herein our clinical experience with gouty arthritis in six heart transplant recipients. PATIENTS AND methods: During a one-year period, six hospitalized male heart transplant patients were seen in consultation for gouty arthritis. Five were subsequently followed for gout as outpatients; the sixth died within six months. Management included trials of nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, allopurinol, and intra-articular steroid injections, as well as attempts to minimize cyclosporine nephrotoxicity. RESULTS: Three patients had gout in remission at time of transplant surgery, and three others developed gout for the first time two to 45 months after transplantation. Following transplant surgery, both pre-existing and new-onset gout appeared to exhibit an accelerated course, with unusually rapid development of chronic polyarticular disease and tophi in four of the five patients followed for more than six months. Peak serum uric acid levels ranged from 11.0 mg/dL to 16.5 mg/dL. NSAIDs produced reversible renal insufficiency in four patients. gout-related infections occurred in three patients, one of whom died. CONCLUSION: Acute gouty arthritis may occur in the heart transplant recipient despite concomitant use of immunosuppressive drugs. cyclosporine, with its attendant hypertension and nephrotoxicity, appears to be the major risk factor for hyperuricemia in this setting, leading to the accelerated development of tophi and chronic polyarthritis. Management is complicated by the patients' renal insufficiency and propensity to infection, as well as by interaction with transplant-related medications. Prevention of hyperuricemia by minimizing cyclosporine nephrotoxicity appears to be the best management strategy, with judicious use of allopurinol for those patients in whom this preventive approach fails.- - - - - - - - - - ranking = 2keywords = hyperuricemia (Clic here for more details about this article) |
5/9. A new variant case of muscle phosphofructokinase deficiency, coexisting with gastric ulcer, gouty arthritis, and increased hemolysis.Muscle phosphofructokinase (PFK) deficiency includes both clinically and genetically heterogeneous conditions. A 22-year-old man with muscle PFK deficiency due to previously unrecognized mutation was admitted because of gastric ulcer. He had noticed mild fatigability on vigorous exercise, but had never experienced painful cramps and myoglobinuria. His history included five time relapses of gastric ulcer and gouty arthritis at ages 19 and 21 years. His laboratory data showing impaired muscle glycolysis, increased hemolysis, and myogenic hyperuricemia had aspects in common with those reported for the classic form of this disease, except that lactate concentrations in his blood increased considerably after exercise. The mutant PFK enzyme of this patient, who was demonstrated to have a missense mutation, could exert some catalytic activity that permitted glycolytic flux in vivo, thus leading to the absence of typical myopathic symptoms. The association of relapsing gastric ulcer with muscle PFK deficiency was detected for the first time. There is a possibility that oxygen radical-induced tissue damage resulting from increased hypoxanthine on exertion plays a role in the pathogenesis of ulceration, since the patient is more tolerant to exercise than reported cases with the classic form of muscle PFK deficiency.- - - - - - - - - - ranking = 1keywords = hyperuricemia (Clic here for more details about this article) |
6/9. gout in the cervical spine: MR pattern mimicking diskovertebral infection.We report the MR features of a surgically proved cervical spine involved with gouty tophi in a patient with a long history of hyperuricemia. Tophi appeared as sharply delineated areas of low signal intensity on T1 and T2 MR images and showed intense and homogeneous signal enhancement on post-contrast images.- - - - - - - - - - ranking = 1keywords = hyperuricemia (Clic here for more details about this article) |
7/9. Fine-needle aspiration biopsy of gouty tophi: lessons in cost-effective patient management.gout, a disease resulting from the effects of hyperuricemia and a crystal-induced arthropathy, may produce soft tissue masses (tophi) which mimick neoplasia clinically and radiographically. We have recently diagnosed three cases of gouty tophus, two of which were clinically suspected to represent sarcomas, by fine-needle aspiration biopsy (FNAB) after extensive radiologic and clinical evaluation. There were two women and one man. aged 71, 73, and 50 yr, with palpable soft tissue masses that involved the right forearm, right hand, and right foot, respectively, Biopsies were obtained by using 25-gauge needles without the aid of general anesthesia. Morphologically, aggregates and disassociated slender, needle-shaped crystals were abundant and easily recognized on both Diff-Quik and Papanicolaou stains. By using a polarizing microscope with a first-order red compensator, the crystals showed negative birefringence, characteristic of sodium urate. Benign-appearing histiocytes, foreign-body-type giant cells, neutrophils, and amorphous debris were scattered among the diagnostic crystals. The diagnosis of gouty tophus can be easily established with FNAB in conjunction with compensated polarizing microscopy. Application of FNAB in the initial evaluation of appropriate soft-tissue masses provides a cost-effective diagnostic method, preventing more costly and often unnecessary clinical and radiologic tests.- - - - - - - - - - ranking = 1keywords = hyperuricemia (Clic here for more details about this article) |
8/9. Gouty arthropathy of the lumbar spine: a case report and review of the literature.STUDY DESIGN: A patient with hyperuricemia developed symptoms from lateral recess stenosis attributed to gouty arthropathy of a lumbar facet joint. OBJECTIVE: To present the diagnosis and management of gouty arthropathy of the lumbar spine in one individual. SUMMARY OF BACKGROUND DATA: The symptoms and treatment of a patient with intra-articular gout of a lumbar facet are presented and contrasted with other cases of spinal extra-articular gout found in the literature. methods: A patient with hyperuricemia reported back pain and symptoms consistent with lateral recess stenosis. Conservative treatment failed, and, after further evaluation, a successful decompressive laminectomy was performed. pathology revealed intra-articular urate crystal deposition. RESULTS: This patient's unilateral S1 radiculopathy corresponded with magnetic resonance and computed tomography studies documenting unilateral lateral L5-S1 lateral recess stenosis secondary to intra-articular gouty arthropathy. As anticipated, the serum uric acid also was elevated. Since surgical decompression with unilateral laminotomy was performed, the patient has been symptom-free for 2 years. CONCLUSION: Although rare, gouty arthropathy of the lumbar facet joint should be considered in all patients with neurologic symptoms and known or suspected gout. Optimization of pharmacologic treatment is indicated for patients suspected of having gouty neuropathy. Surgical decompression is indicated if conservative management with Indocin, nonsteroidal anti-inflammatory agents, and allopurinol fails to reverse neurologic dysfunction.- - - - - - - - - - ranking = 2keywords = hyperuricemia (Clic here for more details about this article) |
9/9. Reversible renal insufficiency, hyperuricemia and gouty arthritis in a case of hypothyroidism.We present the case of a young man with 3-month history of generalized weakness and lethargy, constipation, weight gain, and swelling in the lower extremities. He was found to have an elevated serum creatinine of 203 mumol/l (2.3 mg/dl), markedly elevated TSH, severe hypercholesterolemia, hyperuricemia, a 24-hour urine creatinine excretion rate of 16.8 mmol/d (1.9 g/d), a creatinine clearance of 58 ml/min, and a uric acid excretion rate of 4.2 mmol/d (700 mg/d). With the impression of primary hypothyroidism, the patient was started on levothyroxine supplementation at which point he developed a classic gouty arthritis of right first metatarsophalangial joint. Six weeks after thyroid replacement therapy his serum creatinine had declined to 124 mumol/l (1.4 mg/dl), and 24-hour urine creatinine excretion rate declined to 11.5 mmol/d (1.3 g/d) with an estimated creatinine clearance rate of 65 ml/min. This was accompanied by reduction in serum uric acid and cholesterol levels, and a decline in uric acid excretion rate. Eighteen months later his creatinine had further declined to 88.4 mumol/l (1.0 mg/dl).- - - - - - - - - - ranking = 5keywords = hyperuricemia (Clic here for more details about this article) |