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A patient who suffered from severe deforming arthritis secondary to chronic tophaceous gout with multilobular, solid, tender, enlarged subcutaneous nodules and draining tophi in both hands was evaluated and treated by second ray amputation of the most deformed second finger to provide a more functional result.
A 55-year-old woman was referred to our ward for further evaluation of marked hyperuricaemia and suspected tophi. On physical examination, huge subcutaneous nodules were observed on the knee joints as well as a small nodule on the lateral side of the left sole. Blood chemistry showed marked hyperuricaemia (0.85 mmol/l), hypokalaemia (2.7 mmol/l) and a mild degree of renal insufficiency. Arterial blood gas analysis showed signs of metabolic alkalosis. Daily urinary uric acid excretion on a purine non-restricted diet was 8.9 mmol/day. Uric acid clearance and fractional uric acid clearance were 0.8 ml/min and 2.6%, respectively. Plasma renin activity was 21.8 ng/ml/h, and plasma angiotensin II and aldosterone concentrations were 61 and 121 pg/ml, respectively. However, pressor response to an intravenous administration of angiotensin II was normal. The urinary calcium to creatinine molar ratio was 0.069, and serum magnesium concentration was normal to supranormal. A biopsy of the subcutaneous nodule showed a typical appearance of tophus. Based on these findings, the patient was diagnosed with an atypical case of renal tubular hypokalaemic metabolic alkalosis, with marked hyperuricaemia and tophi as the initial manifestations. So far, only four cases of Bartter's syndrome with gout and/or hyperuricaemia have been described in Japan. This rare case is presented and its mechanism of hyperuricaemia discussed.
Surgical management of acute tophaceous gout of the distal interphalangeal joint is often associated with delayed wound healing. Aspiration through neighbouring uninvolved skin is a safe method of treating these tophi. For persistently symptomatic, unstable DIP joints, arthrodesis should be considered.
Newer approaches to the treatment of gout have included modifications and further attention to aspects of current therapies, and development of interesting new therapies. Colchicine prophylaxis appears to be needed longer than previously recognized after introduction of a urate-lowering agent. Diet has received attention, though most dietary effects are small. New agents under investigation include pegylated formulations of uricase and a new potent xanthine oxidase inhibitor, febuxostat. Some cardiovascular drugs have been shown to be uricosuric.
BACKGROUND: Synovial fluid urates are traditionally measured as supernatants, and levels are reported to be comparable to serum levels. OBJECTIVE: We have decided to attempt to define a more accurate parameter of gouty urate load in the joint fluid. METHODS: In 23 gouty joints of various activity, the urate level was determined by both the traditional method and by heating and agitation to dissolve crystals yielding total joint fluid urate (TJFU). RESULTS: TJFU was higher than the serum level or traditional urate level, and the gradient (TJFU-synovial fluid urate) was proportional to gouty activity. CONCLUSIONS: We propose that TJFU is more representative of the pathophysiology of gout and deserves further evaluation of its implications.
We describe a 53-year-old male renal transplant recipient with hypertension and triglyceridemia, who showed rare manifestations of gout presenting as brownish nodules on the arms and legs as well as chronic tophaceous gouty arthritis of the hands and feet mimicking rheumatoid arthritis, in association with subsequently developed psoriasis of the palms. In elderly Asian men, hypertension and renal insufficiency may be risk factors predisposing to the development of multiple hyperpigmented nodules of tophi in the more proximal extremities.
Infectious arthritis in renal transplant patients may be a commonly diagnosed condition with traditional bacterial organisms isolated. However, since nontuberculous mycobacteria are ubiquitous in the environment, immunocompromised individuals may suffer from infections with these organisms. Concomitant gout and Mycobacterium avium intracellulare septic arthritis is described for the first time in this clinical setting. Appropriate cultures should be performed even in the setting of crystal arthritis in posttransplant patients when clinically indicated.
A double-blind, parallel group study was carried out in 61 patients suffering from acute gouty arthritis to compare the effectiveness of etodolac and naproxen in the relief of symptoms. Patients were allocated at random to receive either 300 mg etodolac twice daily (31 patients) or 500 mg naproxen twice daily (30 patients) for 7 days. Both groups were comparable for sex, age and weight of patients, but there was a tendency for patients in the etodolac group to have more severe gout as shown by baseline clinical assessment scores. The variables assessed on entry and on Days 2, 4 and 7 of treatment were pain intensity, swelling, tenderness, erythema, joint heat, range of motion, and physician's and patients' overall evaluation of the condition. The results showed that there was a significant improvement from baseline in all of the variables at each time point in both treatment groups. However, more etodolac-treated patients (81%) than naproxen-treated patients (53%) showed overall improvement at Day 2, and etodolac was significantly better than naproxen on the Day 2 evaluation of joint swelling and at the Day 4 evaluations of joint tenderness, range of motion and the physician's global assessment. At the final evaluation on Day 7, 97% of the etodolac group reported that their condition had improved as compared to 93% of the naproxen group. Both drugs were well tolerated and only a few mild side-effects were reported.
An elderly female presented with a systemic febrile illness and acute polyarthritis as the first manifestation of gout. She improved dramatically with anti-inflammatory therapy.
An 80-year-old man using diuretics for chronic cardiac failure was diagnosed with tophaceous gout.
Concurrent joint infection with Mycobacterium tuberculosis (TB) and demonstration of intraarticular monosodium urate (MSU) crystals has not previously been reported. We describe a patient with chronic tophaceous gout from whose joints both TB and MSU crystals were isolated. We propose a mechanism to explain this condition.
A 74-year-old man with chronic lymphocytic leukemia, immune purpura, and gout presented with a painful, swollen ankle after a cat bite to his leg. On aspiration of the ankle, gram negative pleomorphic rods and monosodium urate crystals were seen and Pasteurella multocida was cultured. He was treated with ampicillin/sulbactam, joint aspiration, and intraarticular steroids, with resolution of infection and return of joint function. The syndromes of Pasteurella arthritis and crystal arthropathy with septic arthritis are reviewed.
Septic arthritis is a medical and surgical emergency that if left untreated may lead to permanent joint disfigurement and loss of function. In the setting of chronic joint disease, the diagnosis, based on history and physical examination, may be difficult. A case is reported of a patient with a history of aspirate-proven gout presenting with symptoms of typical gouty exacerbation but diagnosed as septic arthritis and pseudogout.
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