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Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 191-193  

Images in medicine - Gouty arthritis

Department of Medicine, Dr DY Patil Medical College, Hospital and Research Centre, Dr DY Patil Vidyapeeth, Pune, Maharashtra, India

Date of Web Publication18-May-2018

Correspondence Address:
Shalaka Suresh Shinde
Department of Medicine, Dr DY Patil Medical College, Hospital and Research Centre, Dr DY Patil Vidyapeeth, Pune, Maharashtra
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Gout is a disorder of uric acid metabolism, characterised by deposition of monosodium urate crystals in joints and periarticular soft tissues as well as renal calculi and chronic nephropathy. The accumulation of crystals in the joints and periarticular soft tissue may cause recurrent episodes inflammatory arthritis. Over the years chronic form may occur with presence of tophi and chronic arthropathy frequently in peripheral and rarely in axial joints. Surgical intervention is usually reserved for cases of recurrent attacks with deformities, severe pain and joint destructions.

Keywords: Acute kidney injury, inflammatory arthritis, joint deformities, monosodium urate crystals, tophi, uric acid

How to cite this article:
Shinde SS, Batra T, Gokhale VS, Kakrani AL. Images in medicine - Gouty arthritis. Med J DY Patil Vidyapeeth 2018;11:191-3

How to cite this URL:
Shinde SS, Batra T, Gokhale VS, Kakrani AL. Images in medicine - Gouty arthritis. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Jan 25];11:191-3. Available from: http://www.mjdrdypv.org/text.asp?2018/11/2/191/232636

  Introduction Top

Gout is a metabolic disease that can manifest as acute or chronic arthritis and deposition of monosodium urate crystals in joints, bones and different body tissues, including the skin and soft tissues. Thus patients presenting with raised uric acid levels should be evaluated thoroughly to avoid further chronic conditions of gouty arthritis. The patients should also be monitored for renal function tests as there is a chance that high uric acid levels can lead to acute kidney injury. The high serum uric acid levels might be reasonable to determine which patients were at higher risk for worsening renal function in the near future and complicating the condition of gout further more. Thus the rare and unique feature about this case is that it showed the correlation of how high serum uric acid levels led to the derangement of renal function tests leading to acute kidney injury and vice versa.

  Case Report Top

A 58-year-old male, resident of Nigdi, Pune, presented with multiple joint pain and difficulty in walking. The patient developed a swelling over the right foot 15 years back along with the elbow joint, wrist joint, and knee joint gradually [Figure 1] and [Figure 2]. He also complained of discharge of pus from few of the swellings. The swellings were painful and did not cause any restriction of the movement at the joint. There were stiffness and tenderness associated with the pain.
Figure 1: Multinodular painful swelling in the foot with pus discharge from one of the sinus

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Figure 2: Bilateral nodular swelling at both the elbow joints

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Differential diagnosis

  1. Rheumatoid arthritis
  2. Septic arthritis
  3. Psoriatic arthropathy
  4. Calcified periarthritis
  5. Acute sarcoidosis
  6. Renal osteodystrophy
  7. Lesch–Nyhan syndrome.

Diagnostic investigation

The laboratory parameters of the patient showed raised serum uric acid levels. The patient was thus treated with tablet febuxostat 40 mg bd and anti-fungal in view of the pus collection. Eventually, within a span of a week, there was a gradual rise in renal function tests (RFTs) of the patient. All other causes of acute kidney injury (AKI) were ruled out. This condition resolved gradually. He was then transferred to plastic surgery department where he underwent the surgery of removal of the lesions. Debridement was performed of the minor swellings. The AKI which had evolved as a consequence of the underlying condition was eventually resolved once the uric acid levels were back to normal. The pus collection from the swelling was taken on a swab and sent to microbiology department for examination [Figure 3]. Deposition of monosodium urate crystals in the bones was seen out of which smears were formed of the crystals on the slide and were sent to the pathology department for further investigation. The monosodium urate crystals were observed under polarizing microscopy [Figure 4].
Figure 3: Pus discharge from one of the sinus collected on the slide for microscopic examination

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Figure 4: Monosodium urate crystals seen under the polarizing microscope

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After clinicopathological workup, the diagnosis of gouty arthritis was made. On starting the treatment, the patient iimproved clinically, and uric acid levels were maintained within normal limits. The patient discharged on tablet febuxostat 40 mg twice a day.

  Discussion Top

This case conveys us to be vigilant about the effects of high serum uric acid levels on kidney and vice versa how deranged RFTs will raise the serum uric acid levels.[1]

The highest incidence occurs in the 65+ years age group, with males more than twice as likely to be afflicted as females.[2]

High uric acid level can be attributed to uric acid elevating drugs, genetic predisposition, and dietary factors.[3]

Gout is a metabolic disorder in which needle-shaped crystal of monosodium urate from supersaturated fluids is deposited in tissues resulting in gouty arthritis, tophi formation, uric acid nephrolithiasis, and renal impairment.[4],[5]

Gout is an inflammatory arthritis caused by cellular reaction to monosodium urate crystal deposition. Tophi are chalky, gritty accumulations of monosodium urate crystals that build up in soft tissue of an untreated gouty joint.[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Iseki K, Oshiro S, Tozawa M, Iseki C, Ikemiya Y, Takishita S, et al. Significance of hyperuricemia on the early detection of renal failure in a cohort of screened subjects. Hypertens Res 2001;24:691-7.  Back to cited text no. 1
Lee SJ, Terkeltaub RA, Kavanaugh A. Recent developments in diet and gout. Curr Opin Rheumatol 2006;18:193-8.  Back to cited text no. 2
Apley and Solomon's Concise System of Orthopaedics and Trauma. 1994. p. 32-5.  Back to cited text no. 3
Emmerson BT. The management of gout. N Engl J Med 1996;334:445-51.  Back to cited text no. 4
Touart DM, Sau P. Cutaneous deposition diseases. Part II. J Am Acad Dermatol 1998;39:527-44.  Back to cited text no. 5
Khandpur S, Minz AK, Sharma VK. Chronic tophaceous gout with severe deforming arthritis. Indian J Dermatol Venereol Leprol 2010;76:69-71.  Back to cited text no. 6
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