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Patients with significant fasciitis in diffuse muscle clusters, SAS should be included as a differential diagnosis.

BACKGROUNDGout is a common metabolic disease characterized by precipitation of monosodium urate crystals in tissues. Typically, it affects peripheral joints of the appendicular skeleton, especially feet and hands. Axial gout can affect any segment of the spine. The actual prevalence of spinal involvement is unknown and may be higher than generally anticipated, as there are many cases of probable axial gout (suggestive computed tomography or magnetic resonance imaging appearance) not associated with spinal symptoms. However, the true frequency of axial disease is still unclear because most cases reported in the literature were not diagnosed by histopathological examination, which remains the gold standard diagnostic procedure. CASE REPORTA 57-year-old woman with hypertension, dyslipidemia, and heart failure secondary to double mitral lesion was admitted to cardiology department for a valve replacement surgery. Two days later, she suddenly presented with thoracic back pain and paraparesis, with slightly hyperactive reflexes, bilateral Babinski sign, and T8 sensory level. Spine magnetic resonance imaging showed a heterogeneous formation inside the vertebral canal, causing anterior dislocation of the spinal cord between T5 and T6. Thus, a thoracic laminectomy was performed, and the intraoperative description showed a fibrotic and caseous epidural lesion invading the lamina and pediculus of T8. To rule out cancer, an intraoperative frozen section was analyzed and revealed osseous and cartilaginous tissues with an exogenous fibrillar material. It was submitted to polarized light microscopy analysis, which exhibited needle-shaped, negatively birefringent crystals. Further histopathological examination confirmed the presence of foreign-body giant cells and excluded infectious diseases and cancer. In view of these findings, an evaluation by the rheumatology team was requested. Despite never being diagnosed with gout, the patient reported a 10-year history of recurring, intense, and short-term attacks of mono-or oligoarthritis affecting the feet (including the first metatarsophalangeal joints), knees, hands, and elbows. She also described eating meat as a trigger for arthritis flare-ups. At physical examination, presence of tophi was observed in both elbows. Laboratory workup revealed a serum uric acid of 11.2 mg/dL. In addition to surgery, treatment for gout was introduced (alopurinol, initially 100 mg/day). Combination with uricosuric therapy will be considered after discharge. CONCLUSIONThis case report illustrates that axial gout must be a differential diagnosis of back pain and spinal cord compression in patients with gout, particularly those with current tophi. The lack of recognition of the problem of spinal involvement in gouty arthritis suggest that this diagnosis may be missed.

BACKGROUNDThe most common etiologic agents of septic arthritis (SA) are Gram-positive organisms (e.g., Staphylococcus aureus), with approximately 15% being due to Gram-positive and Gram-negative organisms. Infection by Pseudomonas aeruginosa occurs typically in patients with a history of intravenous drug use, malignancy, prosthetic devices, and advanced age. SA typically affects one joint but may be polyarticular in up to 20% of cases (most commonly in immunocompromised patients). Here we report a case of polyarticular SA caused by P. aeruginosa in a patient with severe chronic comorbidities. CASE REPORTA 45-year-old male patient was admitted to the gastroenterology department due to a week history of fever and joint pain. From comorbidities, he had a diagnosis of ulcerative colitis with primary sclerosing cholangitis (PSC) and had been submitted to liver transplantation in 2012. However, he had recurrence of PSC with several hospitalizations due to progressive liver failure, hepatic encephalopathy, and infectious complications in the last 3 years. The current clinical picture started with fever (39° C) and painful swelling in the right knee with rapid evolution (3 days) to arthritis in the small joints of the hands, wrists, shoulders, and knees. Physical examination revealed intense pain on palpation and swelling in the hands, wrists, elbows, in addition to marked joint blockage in the right knee. Laboratory tests showed increased acute phase reagents (C-reactive protein 244.9 mg/dL) and impaired renal and hepatic functions. He underwent arthrocentesis and joint lavage of the right knee, as well as antibiotic treatment with ceftriaxone (2 g intravenous IV per day) and vancomycin (2 g IV per day). Blood and synovial fluid cultures showed P. aeruginosa multi-S. In this context, antibiotic therapy was optimized according to antibiogram (cephalosporins) Despite the treatment, the patient evolved with rapidly progressive multiorgan dysfunction and an unfavorable outcome with death.

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