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A 57-year-old man, a recent immigrant from a foreign country, presented to the clinic with a nodule on his elbow. He reported that the nodule had been bothering him for 2 years and had steadily increased in size recently. Further questioning revealed a history of repeated attacks of acute joint pain. The physical examination revealed a rounded, subcutaneous nodule over the elbow, which was tender and rubbery to the touch. The examination was also notable for a subcutaneous nodule at the left metatarsal-phalangeal joint and left metacarpal-phalangeal joint, as well as evidence of arthritis involving both hands
Pathology Laboratory Analysis and Diagnostic procedure The asymmetry and lack of joint space narrowing not seen until advanced stages allow differentiation from other similar-appearing disorders (eg, psoriasis, osteoarthritis, infection, and rheumatoid arthritis). Calcium pyrophosphate dihydrate de-position disease (CPPD) can have symptoms resembling that of gout and can also occur concomitantly in up to 40% of patients with gout. Typically, CPPD involves a different anatomic distribution than gout and is associated with joint space narrowing. Additionally, the absence of erosions and tophi further distinguish CPPD from gout. The most difficult radio-graphic differential diagnostic consideration may be xantho-matosis. The distinction is made by laboratory assessment. Figure 2
Imaging Findings Radiographic examination revealed a classic "punched-out" lytic lesion with an associated overhanging edge at the distal right 1st metatarsal (Figure 1). Multiple other marginal erosions and decreased joint space were seen at several metacarpal-phalangeal joints. A subcutaneous nodule, consistent with a gouty tophus, was identified at the left first metacarpal-phalangeal and left first metatarsal-phalangeal joints (Figure 2). This patient was referred to the rheumatology service for treatment of chronic gouty arthritis. Figure 1
caused by the deposition of the nonopaque crystals within the synovial and cartilagenous tissues. drugs. Radiographic signs are seen in less than half of all afflicted patients and. and steroids. Proliferative osseous change. Renal damage is less common but can occur. although any joint can be affected.3 Computed tomography (CT) . especially if the tophus continues to increase in size. chondrocalcinosis. This particular case is interesting in that although the patient showed no signs of entrapment neuropathy. Males dominate the disease population. and nephropathy. Eventually. with only a 5% female prevalence. Ninety percent of gout is primary or caused by a congenital error of purine metabolism or a defect in the renal excretion of the crystals. Bothersome large tophi can be surgically removed. Secondary gout occurs in 10% of all cases and is the result of increased turnover of nucleic acid. manifested as "punched-out" lesions at the margins of the articular surfaces of the hands and feet.1 Approximately 20% of patients with gout experience urate renal stones.1 Patients most frequently complain of pain in the first metatarsalphalangeal joint. acute gouty arthritis. nonsteroidal anti-inflammatory drugs. or acquired defective renal excretion.Discussion Gout is a metabolic disorder characterized by hyper-uricemia and deposition of monosodium urate monohydrate crystals within the periarticular soft tissues. Treatment of acute attacks of gout involves colchicines. following repeated attacks. he certainly is at risk for developing such an entity. these erosions contain sclerotic borders and are classically Untreated gouty arthritis can result in continued deposition of urate crystals within the soft tissues. Patients generally progress through four distinct phases: asymptomatic hyperuricemia. indicate a late stage of disease. resulting in recurrent painful arthritis. when present. giving the appearance of a subcutaneous nodule known as tophaceous gout (as seen in the patient described). Estrogen is believed to play a protective role. Histologic examination of joint-fluid aspiration shows nonbirefringent monosodium urate crystals within the aspirated bursal fluid. and olecranon bursitis can occasionally be seen in patients with gout. intraosseous cysts. In the described case. there is osseous erosion. Diet and exercise play an important role in the prevention of attacks. Preventative therapy includes allopurinol and uricosuric agents. histologic examination of the tophus revealed birefringent monosodium urate crystals embedded in fibrous tissues. The early radiographic signs of gout are joint effusion and periarticular edema. Laboratory evaluation usually reveals hyperuricemia. chronic tophaceous gout.
Although occasionally seen in the clinical setting. and pseudogout tophi). Radiographic findings are characteristic and include tophi of the great toe and punched-out lesions with overhanging edges. . as effective drug therapy is readily available. Early diagnosis is important. can provide a noninvasive means of differentiating gouty tophi. rheumatoid nodules. magnetic resonance (MR) imaging can provide useful information regarding the effects and extent of crystal deposition within soft tissue. IV.2 Additionally. which demonstrates attenuation measuring 165 HU ± 40. due primarily to today's effective treatment. gout has become a disease of the past.associated with over-hanging edges. Conclusion Gout is a metabolic disorder characterized by urate crystal deposition within soft tissues near or involving joints. Although radiography is the mainstay for the imaging of gout. if left untreated. Osteopenia and the loss of joint space are usually not seen until advanced disease stages.4 from other causes of subcutaneous nodules (eg. cholesterol tophi. the advanced stage is also characterized by joint destruction and severe deformities. Severe attacks of pain can occur and eventual joint destruction takes place.