Gout Initially Mimicking Rheumatoid Arthritis and Later Cervical Spine Involvement

Abstract

Gout is clinically characterized by episodes of monoarthritis, but if not treated properly, it can lead to a chronic polyarthritis, which may eventually mimic rheumatoid arthritis (RA). We present the case of a 59-year-old man, with a history of symmetrical polyarthritis of the large and small joints with later development of subcutaneous nodules, which was initially misdiagnosed as RA, being treated with prednisone and methotrexate for a long period of time. He complained of occipital pain and paresthesia in his left upper limb, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed the presence of an expansive formation in the cervical spine with compression of the medulla. He was admitted for spinal decompressive surgery and the biopsy specimen demonstrated a gouty tophus. Chronic gout can mimic RA and rarely involves the axial skeleton, and thus its correct diagnosis and the implementation of adequate therapy can halt the development of such damaging complications.

Gout involved the cervical disc and adjacent vertebral endplates misdiagnosed infectious spondylodiscitis on imaging: case report and literature review

“…Plain films sometimes appear false negative especially in the early stages and subsequent bone changes are advantageous but nonspecific feature of spinal gout [4, 6, 7, 11]. CT can help visualize the bone and soft tissue changes caused by tophi which appear as low-density area [6, 7, 9, 10]. The typical appearance related to these changes is characterized by punched-out erosion and well-defined margins without surrounding infiltrative changes; structures of vertebrae and endplates can remain unaffected and wedging changes of vertebral bodies are hardly seen [6–10].…”

“…CT can help visualize the bone and soft tissue changes caused by tophi which appear as low-density area [6, 7, 9, 10]. The typical appearance related to these changes is characterized by punched-out erosion and well-defined margins without surrounding infiltrative changes; structures of vertebrae and endplates can remain unaffected and wedging changes of vertebral bodies are hardly seen [6–10]. MRI appears to be sensitive but nonspecific for the diagnosis of spinal gout, but MRI has an obvious advantage in manifesting abundant information of soft tissue in or around the gouty lesion [19–21].…”

“…In 2 cases with enhanced MR images, the involved discs were enhanced significantly [4, 9]. And MR characteristics of 4 patients with tophus were intermediate-to-low signal intensity on T1-weighted images, and on T2-weighted images, the signal intensity varied from low to high [4, 7, 9, 10], which mostly coincided with previous studies [1, 19, 20]. After gadolinium enhancement, the tophi shows homogeneous or heterogeneous enhancement, mainly depending on volumes and distribution of calcification [16].…”

“…And no significant edema was found in the trabecular bone and soft tissue adjacent to the lesions. However, spinal cord edema can sometimes be seen resulting from the cord compression by lesions [5, 7, 10, 11].…”

Obstructive hydrocephalus secondary to odontoid pannus: case report and review of literature

“…Fraser et al [ 6 ] reported a case of confirmed tophaceous gout of the odontoid process that was managed successfully with allopurinol and colchicine alone. It is important to distinguish gouty arthropathy from rheumatoid arthritis as they may mimic one another clinically but the medical management is distinctly different [ 7 ]. Early involvement of the rheumatology team will help ensure that the appropriate medical management is initiated.…”