Rogue one: a story of tophaceous gout in the spine

Abstract

A 26-year-old man with history of extensive tophaceous gout presented to the referring facility with decreased bilateral lower extremity sensation and motor function that began acutely 1 week prior to admission and had progressed to urinary incontinence. The patient was admitted to the intensive care unit due to concern for sepsis secondary to epidural abscess. The patient was started on empiric vancomycin and cefepime. Neurosurgery did not recommend acute neurosurgical intervention given the lack of a compressive lesion. Aspiration of the paraspinal collection by interventional radiology subsequently showed crystals consistent with tophaceous gout. Given the high initial suspicion for gout and results of the paraspinal aspiration, the patient was started on prolonged steroid taper as well as allopurinol and colchicine. The patient eventually had partial neurological recovery with discharge to an inpatient rehabilitation facility for further physical therapy rehabilitation.

Foraminal stenosis and radiculopathy secondary to tophaceous gout: illustrative case

“…For example, there have been cases in which spinal gouty tophus was initially diagnosed as tuberculous tenosynovitis or even malignancy due to the heterogeneous, hyperintense morphology of the lesion. 2 , 6 Although lumbar spinal manifestations are the most common, the literature suggests that a tophus arising from vertebral body or disc space, as in this case, is exceedingly rare. 4 , 9 …”

“…Kostman et al 6 reported two cases initially diagnosed as tuberculous tenosynovitis that were later discovered to be gouty tophi when symptoms persisted refractory to antibiotics. Dwarki et al 2 illustrated gouty tophus masked as a malignancy on MRI due to the heterogeneous, hyperintense morphology of the lesion. Other case reports of gout tophus in the spine demonstrate a similar morphology to other intraspinal compressive morphologies with nonspecific overgrowth into surrounding tissues.…”

“…1 Although gout most commonly affects the joints of the hands and feet, it can also affect the spine, leading to tophaceous deposits and potential neurological symptoms. 2 Depending on location, gouty tophi in the spine have a constellation of presentations that often mimic other much more common pathologies such as nerve root compression from disc herniation or synovial cyst formation. 3 There is limited literature available on tophaceous gout in the spine, mostly rare case reports or small series with some literature reviews.…”

Acute presentation of spinal gouty arthritis: A case report and review of literature

“…[4] As of 2019, only 159 cases of spinal gout have been reported; gout is typically diagnosed in the fourth decade of life, the average age in men 30 years old. [2] Around 50% of patients present with neurological sequela requiring surgery if there is a neurological compromise. Here, our patient required surgical decompression/fusion to both establish the diagnosis and treat the acute paraparesis.…”

Crystal Diseases of the Spine

“…Other presentations are rare and include predominant or isolated paraspinous, paravertebral, epidural, and/or foraminal tophi, 12,[18][19][20] involvement of the atlantoaxial joint with subsequent subluxation or cord compression via mass effect, 21,22 and involvement of the filum terminale. 23…”