Case Of Gout Research Articles

原著1関節リウマチと診断され,投与されたブシラミンによってブシラミン腎症を併発し,ミゾリビンにより腎障害の増悪をきたした慢性結節性痛風の1例

原著1関節リウマチと診断され,投与されたブシラミンによってブシラミン腎症を併発し,ミゾリビンにより腎障害の増悪をきたした慢性結節性痛風の1例

Tophaceous gout of the lumbar spine mimicking pyogenic discitis

Gout of the spine is very rare. Forty-one cases of gout affecting the spine have been reported. To present a patient with tophaceous gout of the lumbar spine mimicking pyogenic discitis. Case report. The medical record, including operative notes, progress notes, discharge summary, clinical notes, radiological study, and pathological studies was reviewed. The patient had acute low back pain and radiculopathy with high spiking fever. Therefore, pyogenic discitis was suspected. However, histological diagnosis revealed tophaceous gout. Tophaceous gout of the spine is very rare. However, when a patient presents with acute back pain and fever, spinal gout should be considered, particularly in a patient with a previous history of hyperuricemia or gout.

Discussion Following Cases 1 and 2

In both the case of acute gouty attack presented by Dr. Arthur L. Weaver (Case 1; Patient NZ)1 and the case of acute gout and bacterial infection that I presented (Case 2; Patient PA),2 the outcome ultimately was positive. However, these 2 cases illustrate several potential decision points at which care could be improved.

Excellent response to the clinical treatment of tophaceous gout

Gout continues to be a health problem around the world, and the treatment may turn into a real challenge when the patient presents a certain degree of chronic renal failure (CRF). We discuss a case of tophaceous gout in a 68-year-old male patient without urolithiasis and with uric acid (UA) underexcretion and CRF (creatinine clearance of 42 ml/min). Uricosuric treatment with benzbromarone and urinary alkalinization was administered, and acute gouty attacks improved substantially. Subsequently, allopurinol was added to the treatment to accelerate tophi reduction in the hands, feet, elbows and knees. After 30 months of treatment, serum UA declined from 10 to 3.2 mg/dl. Urinary UA excretion of 0.44 g/24 h in the baseline rose to 0.85 g/24 h, returning to the baseline value after 30 months. UA clearance tripled, rising from 3.05 ml/min before treatment to 9.48 ml/min, and remained at this level. It is worth stressing that even in cases of severe tophaceous gout, the response to clinical treatment may be satisfactory with substantial reduction of tophi and full acute gouty attack remission even in patients presenting a certain degree of CRF.

Spinal gout in a renal transplant patient: a case report and literature review

Background Gout in the axial spine is rare. We present a case report on a renal transplant patient who developed fever and acute back pain at the L5 through S1 level secondary to sodium urate deposits. We review the literature on this rare disease and propose a management algorithm based on a resulting analysis. Case Description A 37-year-old man with a history of gout and a renal transplant for IgA nephropathy presented with acute back pain and fever without evidence of neurological deficits. Magnetic resonance imaging revealed a uniformly contrast-enhancing infiltrative process involving the right pedicle, lamina, and inferior facet of the L5 vertebra. Computed tomography–guided needle biopsy revealed a friable white tissue consistent with sodium urate crystals. Conservative treatment with steroids and narcotics was used with good symptomatic relief. Conclusion Although few cases of gout involving the spine have been reported, its prevalence is likely grossly underestimated. Most patients have a history of gout and have elevated levels of serum urate level on presentation. The disease most commonly involves the lumbar spine. Patients usually have neurological deficits on presentation, and surgical decompression produces favorable outcomes. However, conservative medical management is appropriate for those with back pain only. Aggressive control of hyperuricemia is essential regardless of the method of treatment.

Crystal-induced arthropathies: recent investigative advances

To highlight recent investigations that have stimulated renewed interest in crystal-induced arthropathies. Specific diet-related and alcohol-related risks for gout have been clarified, and alternative urate-lowering treatments likely to benefit patients with difficult-to-treat gout are in development. Progress toward understanding mechanisms underlying the renal deficits defining most cases of gout includes characterization of a urate-specific renal tubule transporter explaining many aspects of renal uric acid handling and identification of mutations in the UMOD gene, resulting in altered uromodulin protein in the gout-associated disorders familial juvenile hyperuricemic nephropathy and medullary cystic kidney disease type 2. A genetic marker associated with the risk for severe allopurinol toxicity has been reported. Hyperuricemia and gout are increasing in incidence, as is complicated gout, especially among the elderly and patients with cardiovascular and renal comorbidities, organ transplants, or complex concomitant medication regimens. Asymptomatic hyperuricemia is clearly associated with hypertension, chronic kidney disease, cardiovascular disease, and the insulin resistance syndrome, and the pathogenetic significance of these associations is under intensive study. Mutation in the ANKH gene has been found among some patients with sporadic as well as familial calcium pyrophosphate deposition disease. The results of these clinical, epidemiologic, experimental, and therapeutic investigations presage advances in the management of crystal-induced arthropathies.

A rare cause of spinal cord compression: imaging appearances of gout of the cervical spine

Gout is a metabolic disorder typically affecting the peripheral joints, more commonly in males. Spinal involvement is uncommon and is usually associated with hyperuricemia. We present the imaging findings of a case of spinal gout in a female patient with no previous history of hyperuricaemia, involving multiple spinal segments.

Molecular diagnosis of avian nephritis: Preliminary report

Kidney samples from chickens diagnosed with acute nephritis and gout were subjected to histological and electron microscopic examination. The investigations revealed cytoplasmic inclusion bodies in the tubular epithelial cells containing round virions of about 30 nm in diameter. Since avian nephritis virus (ANV) is known as a potential causative agent of the so-called baby chick nephropathy, an RT-PCR assay was developed for the molecular detection of ANV-specific nucleic acid in the specimen. The specificity of the assay was confirmed by direct sequencing of the amplicon obtained in the reaction. The nucleotide sequence of the PCR product showed 92% identity with the reference ANV sequence deposited in the GenBank database. After having been validated on some other suspicious cases of avian nephritis, the PCR method described in this study can be a potential tool for routine diagnostic examination of samples submitted from cases of gout and nephropathy in chickens.

台湾における若年性痛風の臨床検討

The increasing proportion of patients showing a family history and renal insufficiency in gout suggests that genes for gout may be closely linked with familial juvenile hyperuricemic nephropathy (FJHN), especially for those with precocious onset of gouty attack. This study investigated the clinical features of juvenile gout as well as its possible association with FJHN. A total of 543 cases of juvenile gout with onset of gouty attack earlier than 20 years of age listed in the Hoping Gout Database were enrolled, and 5,269 gouty cases with the onset age between 40 to 50 years were selected as control group. The body weight, height and body mass index in juvenile gout were significantly higher than those in the control group (P<0.0001). The number of joints involved and the percentages of hypertension, diabetes, hyperlipidemia and nephrolithiasis in juvenile gout were significantly lower than those in the control group (P<0.0001). There was no significant difference in the percentage of female gout and tophaceous gout between the two groups. Serum orate level,24-hour urinary uric acid excretion and creatinine clearance in juvenile gout were significantly higher than those in the control group (P<0.0001). The percentage of renal insufficiency in juvenile gout was only 9.8% and was significantly lower than that in the control group (P<0.0001). The percentage of familial aggregation in juvenile gout was about 1.9-fold higher than that in control group (44.3% vs.23.8%, P<0.0001). Among patients with a family history juvenile gout shows a significantly higher proportion of heritage from the father (P<0.0001) and a significant lower proportion of heritage from the sibs and mother than the control group (P<0.0001 for both). In conclusion, juvenile gout is associated with both excessive weight and hereditary background, while the FJHN gene may not be the main gene responsible for juvenile gout in Taiwan.

Rasburicase treatment in severe tophaceous gout: a novel therapeutic option

We recently encountered a destructive case of tophaceous gout in a 57-year-old patient. Despite perfect therapy compliance, the patient failed in the conventional urate-lowering treatment, accounting for the ongoing urate retention and accumulation with progressive tophaceous bulky disease. Application of an experimental scheme of uricolytical therapy on this patient was able to reduce bulky disease significantly. In modern medicine, potent urate-debulking medication with urate oxidase (uricase) derivatives is at our disposal, and it is a challenge for rheumatologists to install the right strategy including innovative approaches with potent uricolytic therapy on the right patient at the right time.

Tophaceous gout presenting as a dorsal nasal lump

A literature review reveals that gout has been described as affecting many sites in the head and neck region, both in the arthritic and tophaceous form. Gout can often mimic malignancy or infection, and has been described as causing acute airway problems requiring emergency tracheotomy. Here we describe the first published case of tophaceous gout affecting the soft tissues overlying the nasal bones. The patient presented with a bony, hard, dorsal hump and requested aesthetic rhinoplasty. We also describe an endoscopic technique for removal of tophi using a powered microdebrider system with a protected burr head. Endoscopic powered microdebrider blade excision of tophi affecting the limbs has already been described, with reduced complications when compared with conventional curettage and debridement techniques. This is the first such application to the nose.

Obesity, Weight Change, Hypertension, Diuretic Use, and Risk of Gout in Men

Limited prospective information exists on the relation between obesity and weight change and the risk of gout. Similarly, both hypertension and diuretic use have been considered risk factors for gout; however, their independent contributions have not been established prospectively. We prospectively examined over a 12-year period (1986-1998) the relation between adiposity, weight change, hypertension, and diuretic use and incident gout in 47,150 male participants with no history of gout at baseline. We used a supplementary questionnaire to ascertain the American College of Rheumatology criteria for gout. During 12 years we documented 730 confirmed incident cases of gout. Compared with men with a body mass index (BMI) of 21 to 22.9, the multivariate relative risks (RRs) of gout were 1.95 (95% confidence interval [CI], 1.44-2.65) for men with a BMI of 25 to 29.9, 2.33 (95% CI, 1.62-3.36) for men with a BMI of 30 to 34.9, and 2.97 (95% CI, 1.73-5.10) for men with a BMI of 35 or greater (P for trend <.001). Compared with men who had maintained their weight (+/-4 lb) since age 21 years, the multivariate RR of gout for men who had gained 30 lb or more since age 21 years was 1.99 (95% CI, 1.49-2.66). In contrast, the multivariate RR for men who had lost 10 lb or more since the study baseline was 0.61 (95% CI, 0.40-0.92). The multivariate RRs of gout were 2.31 (95% CI, 1.96-2.72) for the presence of hypertension and 1.77 (95% CI, 1.42-2.20) for diuretic use. Higher adiposity and weight gain are strong risk factors for gout in men, while weight loss is protective. Hypertension and diuretic use are also important independent risk factors for gout.

Intra-abdominal gout mimicking pelvic abscess

Gout is the most common crystal-induced arthritis. Gouty tophi typically deposit in the extremities, especially toes and fingers. We present an unusual case of intrapelvic tophaceous gout in a patient suffering from chronic gouty arthritis. CT and MRI of the abdomen and pelvic cavity disclosed calcified gouty tophi around both hips, and a cystic lesion with peripheral enhancement in the pelvic cavity along the course of the iliopsoas muscle. The intra-abdominal tophus mimicked pelvic abscess.

A case of female premenopausal tophaceous gout requiring surgical management

We report a case of tophaceous gout in a 32-year-old woman who had suffered from anorexia nervosa since the age of 15. She had been taking a diuretic, mainly furosemide, to lose weight since she was 18. She was referred for orthopedic surgery because of a tophus at her right metatarsophalangeal joint. Because of a discharging sinus associated with the tophaceous deposits, surgery was performed. Use of the diuretic was stopped after surgery and the serum uric acid concentration returned to normal. It was thought that long-term abuse of a diuretic induced the tophaceous gout in this premenopausal woman.

Alcohol intake and risk of incident gout in men: a prospective study

The association between alcohol consumption and risk of gout has been suspected since ancient times, but has not been prospectively confirmed. Additionally, potential differences in risk of gout posed by different alcoholic beverages have not been assessed. Over 12 years (1986-98) we used biennial questionnaires to investigate the relation between alcohol consumption and risk of incident gout in 47?150 male participants with no history of gout at baseline. We used a supplementary questionnaire to ascertain whether reported cases of gout met the American College of Rheumatology survey gout criteria. We documented 730 confirmed incident cases of gout. Compared with men who did not drink alcohol, the multivariate relative risk (RR) of gout was 1.32 (95% CI 0.99-1.75) for alcohol consumption 10.0-14.9 g/day, 1.49 (1.14-1.94) for 15.0-29.9 g/day, 1.96 (1.48-2.60) for 30.0-49.9 g/day, and 2.53 (1.73-3.70) for > or =50 g/day (p for trend <0.0001). Beer consumption showed the strongest independent association with the risk of gout (multivariate RR per 12-oz serving per day 1.49; 95% CI 1.32-1.70). Consumption of spirits was also significantly associated with gout (multivariate RR per drink or shot per day 1.15; 95% CI 1.04-1.28); however, wine consumption was not (multivariate RR per 4-oz serving per day 1.04; 95% CI 0.88-1.22). Alcohol intake is strongly associated with an increased risk of gout. This risk varies substantially according to type of alcoholic beverage: beer confers a larger risk than spirits, whereas moderate wine drinking does not increase the risk.

Purine-rich foods, dairy and protein intake, and the risk of gout in men.

Various purine-rich foods and high protein intake have long been thought to be risk factors for gout. Similarly, the possibility that the consumption of dairy products has a role in protecting against gout has been raised by metabolic studies. We prospectively investigated the association of these dietary factors with new cases of gout. Over a 12-year period, we prospectively examined the relationship between purported dietary risk factors and new cases of gout among 47,150 men who had no history of gout at base line. We used a supplementary questionnaire to ascertain whether participants met the American College of Rheumatology survey criteria for gout. Diet was assessed every four years by means of a food-frequency questionnaire. During the 12 years of the study, we documented 730 confirmed new cases of gout. The multivariate relative risk of gout among men in the highest quintile of meat intake, as compared with those in the lowest quintile, was 1.41 (95 percent confidence interval, 1.07 to 1.86; P for trend = 0.02), and the corresponding relative risk associated with seafood intake was 1.51 (95 percent confidence interval, 1.17 to 1.95; P for trend = 0.02). In contrast, the incidence of gout decreased with increasing intake of dairy products; the multivariate relative risk among men in the highest quintile, as compared with those in the lowest quintile, was 0.56 (95 percent confidence interval, 0.42 to 0.74; P for trend <0.001). The level of consumption of purine-rich vegetables and the total protein intake were not associated with an increased risk of gout. Higher levels of meat and seafood consumption are associated with an increased risk of gout, whereas a higher level of consumption of dairy products is associated with a decreased risk. Moderate intake of purine-rich vegetables or protein is not associated with an increased risk of gout.

Influence of Leflunomide on Renal Handling of Urate and Phosphate in Patients with Rheumatoid Arthritis

Reduction of serum urate and phosphate levels has been observed in patients receiving leflunomide therapy, but the mechanism for such changes has not been evaluated. Thirty-eight patients with rheumatoid arthritis who began leflunomide were studied. Serum urate, creatinine, and phosphate, and 24-hour uric acid, creatinine, and phosphate were measured before, during, and in some instances after leflunomide treatment. Clearances of urate and creatinine, fractional excretion of urate, and tubular reabsorption of phosphate were calculated. Undissociated urinary uric acid was estimated with a nomogram. Twelve patients gave consent to withdraw leflunomide treatment of a 2-week period and underwent a third study. Decreases in serum urate and phosphate levels were observed, with parallel increases in clearances of urate and in fractional excretion of urate, and a reduction in tubular reabsorption of phosphate. Clearances of creatinine and undissociated urinary uric acid remained unchanged. Two weeks after withdrawing the drug, a partial return toward baseline values was observed, but residual changes were apparent. No case of clinical gout was observed. Leflunomide enhances urate and phosphate loss, an effect that partially persisted after 2-week withdrawal. The long-term effect of mild phosphate wasting warrants further investigation. The urate-lowering effect of leflunomide may be useful in monitoring compliance in leflunomide therapy.

Tendinite goutteuse révélatrice d’une observation de glycogénose type1a de l’adolescent

Introduction. – Hyperuricemia is a known consequence of glucose-6-phosphatase deficiency. Very few cases of tophaceous gout revealing a glycogen storage disease type 1a have been described. Case report. – A 17 years-old adolescent presents with tophaceous gout of Achilles’ right heel. The diagnosis of glycogen storage disease type 1a is suggested by blood chemical studies ( hyperlactacidemia, hypercholesterolemia) and confirmed by hepatic enzyme dosage. Mutation analysis reveals a novel mutation. Both the index case and his sister are compound heterozygotes for the mutations R83C/M5R. Conclusion. – When a mutation in the glucose-6-phosphatase gene is discovered, be it a homozygous or heterozygous mutation and when associated with evocative symptoms, then the diagnosis of glycogen storage disease type 1a can be made without hepatic biopsies.

Blister as the Initial Presentation of Gout

We present a case of gout that presented initially as a bullous lesion. The patient had no history of gout, and the lesion was diagnosed initially as a simple pressure sore. Examination revealed a large blister over the right medial first metatarsophalangeal joint. Aspiration of the blister yielded cloudy fluid, with many monosodium urate crystals present on microscopic examination. There is scant literature on bullous lesions in gout. Such lesions can occur in patients known to have gout or can lead to the diagnosis of gout in previously undiagnosed patients. Gouty blisters likely form at sites of trauma, as has been proposed for gouty tophi. This case also emphasizes the importance of careful clinical and microscopic examination of aspirated fluid for crystals in the diagnosis of gout.

きわめて稀な第 I 趾基節骨に発生した若年性痛風の1例

きわめて稀な第 I 趾基節骨に発生した若年性痛風の1例