Tophaceous Deposits Research Articles

History of Treatments Used to Treat Gout and Hyperuricemia

ABSTRACT: Treatment of arthritis has been gaining momentum most recently with new advancement in technology and various modes of treatment available. But; with changing life-style and unhealthy dietary habits; cases of hyperuricemia and gout are increasing at an alarming rate. Gout attacks joints and the Heat, inflammation, discomfort, inflammation, and intense discomfort are a few symptoms. Inhibitors of Xanthine Oxidase used in treatment for hyperuricemia and arthritis which reduce the serum urate level. Study on further applications of medications to combat hyperuricemia and gout is currently under way which has a scope for further development. synthesis of inhibitors of Xanthine Oxidase has been showing for preventing tophaceous deposits from accumulating. Many different methods have been used to combat hyperuricemia throughout the history and many different modes of treatment are currently employed which provide relief from hyperuricemia and gout due to the advancement in technology. The advancement in modern science has ensured that the treatment of hyperuricemia and gout has developed rapidly to effectively treat the disease which has been increasing at an alarming rate in the last two decades. Emphasis has also been given to find out new breakthroughs in the discovery of alternatives for traditional drugs that are used to treat hyperuricemia and gout which will provide relief to patients.

Musculoskeletal CT Imaging: State-of-the-Art Advancements and Future Directions.

CT is one of the most widely used modalities for musculoskeletal imaging. Recent advancements in the field include the introduction of four-dimensional CT, which captures a CT image during motion; cone-beam CT, which uses flat-panel detectors to capture the lower extremities in weight-bearing mode; and dual-energy CT, which operates at two different x-ray potentials to improve the contrast resolution to facilitate the assessment of tissue material compositions such as tophaceous gout deposits and bone marrow edema. Most recently, photon-counting CT (PCCT) has been introduced. PCCT is a technique that uses photon-counting detectors to produce an image with higher spatial and contrast resolution than conventional multidetector CT systems. In addition, postprocessing techniques such as three-dimensional printing and cinematic rendering have used CT data to improve the generation of both physical and digital anatomic models. Last, advancements in the application of artificial intelligence to CT imaging have enabled the automatic evaluation of musculoskeletal pathologies. In this review, the authors discuss the current state of the above CT technologies, their respective advantages and disadvantages, and their projected future directions for various musculoskeletal applications.

A case of Tophaceous Pseudogout: A Rare Crystalopathy Particularly Afflicting the Temporomandibular Joint

<h3>Introduction</h3> Tophaceous pseudogout is a rare variant of CPPD crystal deposition disease presenting with a soft- tissue calcified mass. Temporomandibular joint is a common site of involvement of tophaceous pseudogout. Mu- tations in gene ANKH (inorganic phosphate transport regulator) are involved in crystal related inflammatory reac- tions. <h3>Materials and Methods</h3> We report a case of Tophaceous CPPD crystal deposition disease. A 77-year old female with no pertinent past medical or drug history, presented with persistent dull pain in her left TMJ and gradual change in occlusion over two years with intermittent trismus. Clinical examination revealed a left pre-auricular swelling with compression of the left EAC. CT imaging showed a radiopaque expansile mass encompassing the left TMJ. Surgical removal was performed together with alloplastic reconstruction using a TMJ Concepts Total Joint Replacement prosthesis. <h3>Results</h3> Microscopic examination revealed a low-grade cartilaginous proliferation with intensely basophilic calcified crys- tal deposits which were rhomboidal in appearance and polarized weakly. Few areas showed atypical, occasional binucleated chondrocytes interpreted as chondroid metaplasia. No significant bone or soft tissue invasion was identified. The clinical, histological and radiographic findings were consistent with tophaceous pseudogout (mas- sive CPPD deposition with cartilaginous metaplasia). Post-operatively the patient was pain-free with normalized occlusion and function. <h3>Conclusions</h3> Distinction from other benign chondroid neoplasms such as osteochondroma, synovial chondromatosis which may mimic CPPD disease is important. Low grade chondrosarcoma should be excluded, especially in decalcified sec- tions from which the CPPD crystals may be lost leaving behind only the atypical features in metaplastic chondro- cytes. Tophi of gout needs to be discriminated too, where monosodium urate crystals are more needle shaped and negatively birefringent under polarized light microscopy, besides hydroxyapatite crystals which appear as non- birefringent clumps. Correct identification of the type of crystal deposition is paramount to the treatment of crystal arthropathy as the underlying metabolic disturbances may be quite specific.

Operative management of gouty tophi in the region of the olecranon: a case series.

BackgroundTophaceous gout affecting the olecranon region can result in local discomfort, skin ulceration, secondary infection, and considerable disability if left untreated. However, there are limited reports of outcomes, including postoperative complications and recurrence after surgical excision of tophaceous gout deposits at the elbow. The aim of this study is to present our surgical technique and minimum one-year outcomes after surgical excision of tophaceous gout involving the elbow.MethodsA retrospective chart review was performed on all patients from a single surgeon's practice who underwent surgical excision of gouty tophi of the elbow between January 2016 and December 2019. The indications for surgical excision of tophi included failure of medical management, presence of skin ulceration, and/or large gouty tophi. The relevant data pertaining to patient demographics, preoperative findings, intraoperative findings, surgical pathology reports, and short-term postoperative complications were collected through retrospective chart review. Patients were subsequently contacted for a follow-up telehealth visit to assess recurrence of gouty tophi, functional outcomes, and range of motion (ROM) measurements.ResultsSix male patients underwent 7 total procedures (1 bilateral elbow) during the study period. The mean age of the cohort at the time of surgery was 56.0 ± 7.1 years (range: 45.3-63.5). The mean size of the swelling in 2 maximum dimensions was 5.8 × 3.4 cm. There were no intraoperative or immediate postoperative wound complications. There was no recurrence of gouty tophi at a mean follow-up time of 30.8 months (range: 14.0-43.5). Patients reported physiologic ROM (mean flexion-extension arc of 2°-134°) with no pain at final follow-up.ConclusionSurgical treatment of tophaceous gout of the elbow is associated with a low risk of wound complication and recurrence.

What’s new on the front-line of gout pharmacotherapy?

ABSTRACT Introduction Gout is the most common form of inflammatory arthritis affecting millions of persons around the world. Painful flares and tophaceous deposits are debilitating, reduce quality of life and put strain on health-care systems. Areas Covered This review provides an overview of the treatment of gout flares and lowering serum urate. First line agents are discussed with emphasis on emerging evidence. Novel therapies are also covered. Expert opinion Lifestyle modifications form a part of gout prevention. NSAIDs, colchicine, and glucocorticoids are first line agents for gout flares. The IL-1β antagonists are highly effective for arresting flares but their cost-effectiveness render them salvage therapies. Allopurinol is an agent of first choice for urate lowering therapy. In Southeast Asian and Black populations, screening for HLA*B58:01 mutation is a cost-effective approach to decrease the occurrence of allopurinol hypersensitivity syndrome. Febuxostat is another efficacious urate lowering therapy, but has received a U.S. FDA black box warning for cardiovascular safety. Novel uricosurics are a class for continued drug development; verinurad and arhalofenate are agents with future promise. For patients with recalcitrant gout, pegloticase is effective. Its immunogenicity significantly threatens the achievement of sustained urate lowering responses. Abrogating pegloticase’s immunogenicity with immunomodulatory co-therapy may lend to sustained efficacy.

Gradual reduction of tophaceous deposits during urate-lowering therapy.

Gradual reduction of tophaceous deposits during urate-lowering therapy.

Gout In Extremis: Massive Soft Tissue Tophaceous Deposits

Gout In Extremis: Massive Soft Tissue Tophaceous Deposits

Lumbar Gout Tophus Mimicking Epidural Abscess with Magnetic Resonance Imaging, Bone, and Gallium Scans.

Gout is a common metabolic disorder, typically diagnosed in peripheral joints. Tophaceous deposits in lumbar spine are a very rare condition with very few cases reported in literature. The following is a case report of a 52-year-old patient with low back pain, left leg pain, and numbness. Serum uric acid level was in normal range. magnetic resonance imaging, bone scan, and gallium-67 images suggested an inflammatory-infectious process focus at L4. After a decompressive laminectomy at L4–L5 level, histological examination showed a chalky material with extensive deposition of amorphous gouty material surrounded by macrophages and foreign-body giant cells (tophaceous deposits).

Assessment of cardiovascular risk profile based on measurement of tophus volume in patients with gout.

Hyperuricemia and gout are associated with increased risk of cardiovascular disease and metabolic syndrome. The aim of this study was to evaluate the correlation of total tophus volumes, measured using dual-energy computed tomography, with cardiovascular risk and the presence of metabolic syndrome. Dual-energy computed tomography datasets from 91 patients with a diagnosis of gout were analyzed retrospectively. Patients who received urate lowering therapy were excluded to avoid the effect on tophus volume. The total volumes of tophaceous deposition were quantified using automated volume assessment software. The 10-year cardiovascular risk using the Framingham Risk Score and metabolic syndrome based on the Third Adult Treatment Panel criteria were estimated. Fifty-five and 36 patients with positive and negative dual-energy computed tomography results, respectively, were assessed. Patients with positive dual-energy computed tomography results showed significantly higher systolic blood pressure, diastolic blood pressure, fasting glucose, and higher prevalence of chronic kidney disease, compared with those with negative dual-energy computed tomography results. The total tophus volumes were significantly correlated with the Framingham Risk Score, and the number of metabolic syndrome components (r = 0.22 and p = 0.036 and r = 0.373 and p < 0.001, respectively). The total tophus volume was one of the independent prognostic factors for the Framingham Risk Score in a multivariate analysis. This study showed the correlation of total tophus volumes with cardiovascular risk and metabolic syndrome-related comorbidities. A high urate burden could affect unfavorable cardiovascular profiles.

Management of Gout.

Gout, or monosodium urate crystal deposition disease, is caused by supersaturation of extracellular fluid with urate. The prevalence of gout in the United States is reported to be 8.4 cases per 1000 individuals, but this estimate is based on patient self-reporting and may overestimate or underestimate true prevalence by up to twofold [1]. The clinical manifestations of gout include recurrent attacks of acute inflammatory arthritis, accumulation of urate crystals in the joints and periarticular tissue (ie, tophaceous deposits), and uric acid nephrolithiasis. Monosodium urate crystals present in synovial fluid are clearly involved in the pathogenesis of gout [2]. Urate crystals in synovial fluid can be identified in clinical practice by use of polarized light microscopy, providing the means for a rapid, definitive diagnosis. Gout is most often first suspected when presenting with dramatic acute monarthritis in a joint in the lower extremity. Effective therapies are available to treat the acute inflammatory attacks of gout and to reverse and prevent the chronic destructive manifestations of urate crystal deposition. Although these treatments have favorably changed the course of gout in the great majority of patients, the disease still may be difficult to treat in noncompliant or poorly instructed patients [3,4] and in patients with comorbid medical conditions, particularly those with chronic renal insufficiency.

Bipartite patella associated with tophaceous invasion: A rare case report

We report the case of 32-year-old male who had a painful knee due to tophus formation in the interosseous area of the bipartite patella. There was neither a history of previous trauma to his patella nor a family history of gouty arthritis. Intraoperatively, we found chalky white-yellow material deposited at the bipartite space and it was curetted. The second part of the patella was fixed by a screw for functional preservation. In addition, hyperuricemia was also noted and controlled by uricosuric agents postoperatively. Gout should be included in the differential diagnosis of painful bipartite patella, and we suggest surgical intervention in combination with antihyperuricemic therapy for tophaceous deposits of the bipartite patella.

Tophaceous gout in thalassemia intermedia: a rare association.

A 32-year-old male presented with progressive swelling of fingers of both hands and joint pains. On physical examination, the patient had severe pallor, frontal bossing, zygomatic prominence, malocclusion of teeth and tophaceous deposits at knuckles and pinna (Fig. 1a). There was mild hepatomegaly and massive splenomegaly. On investigation, his hemoglobin was 6.1 g/dl (normal levels 13–17 g/dl), and he had microcytic normochromic anemia. He also had elevated uric acid levels of 14 mg/dl (normal levels 3.5–7 mg/dl) suggesting a hypermetabolic state. Chest and skull radiograph showed extramedullary hematopoiesis; skull radiograph revealed sun-ray appearance. Plain radiograph of the hands showed erosion of few phalanges, soft tissue swelling and ‘punched-out’ lytic lesions with sclerotic margins and overhanging bony edges (Martel's sign) [1] (Fig. 1b). Joint fluid aspiration revealed needle-shaped birefringent monosodium urate crystals. A genotypic diagnosis of double heterozygous thalassemia with hemoglobin E trait and phenotypic diagnosis of thalassemia intermedia with secondary chronic tophaceous gout was made. Crystal proven gout in a patient with thalassemia intermedia is a rare but important association. Figure 1: (a) Tophaceous deposits at pinna and (b) Martel's sign.

Beyond Joints: a Review of Ocular Abnormalities in Gout and Hyperuricemia.

Gout is a common inflammatory arthritis among middle-aged men and postmenopausal women and can be a debilitating disease. Gout results from an elevated body uric acid pool, which leads to deposition of monosodium urate (MSU) crystals, mainly in and around the joints. The MSU crystals trigger release of proinflammatory cytokines, such as interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α. Ocular manifestations have been uncommonly reported in patients with gout. These include descriptions of tophaceous deposits in different locations of the eye including the eyelids, conjunctiva, cornea, iris, sclera, and orbit. Some depositions were coincidentally diagnosed in asymptomatic patients, while the majority were symptomatic. Other ocular abnormalities include dry eye syndrome, red eye, uveitis, intraocular hypertension, glaucoma, and cataracts. Herein, we review the medical literature pertaining to ocular manifestations in gout and hyperuricemia and propose a possible association between ocular abnormalities, hyperuricemia, and gout, including their common risk factors and comorbidities.

Le « genou microcristallin » ou « arthropathies du genou associées aux maladies microcristallines »

The knee joint is frequently involved with crystal-associated deposits and arthritis. Gout and tophaceous deposits can involve the knee joint and periarticular structures, at any time over the disease progression. Typical acute flares as well as tophaceous deposits at the trochlea surface, in patellar and quadricipital tendon can occur. Fracture of the patella is a rare complication of patella tophus. Acute arthritis related to calcium pyrophosphate (CPP) crystals is the hallmark of the elderly. Apatite deposits, related to basic calcium phosphate (BCP), might occur in any enthesitic site around the knee joint. Clinical symptoms are similar to those observed at the rotator cuff, from asymptomatic deposits to acute periarthritis. By contrast calcium crystal deposits in menisci, hyaline cartilage and upper tibiofibular joint can be formed by CPP or BCP crystals, in various proportions, and lead to chondrocalcinosis, a pure radiographic description. Recently crystal-induced arthritis has been described at knee joint prosthesis with septic prosthesis as differential diagnosis.

Thoracic spinal cord compression by extradural tophus: a case report and review of the literature

Case report and literature review. Gouty arthritis of the spine is rare. Gout presenting as back pain and quadriplegia may be difficult to distinguish from a spinal tumor. Symptoms vary, and the diagnosis is often delayed. We report an unusual case of thoracic spinal cord compression caused by extradural tophaceous deposits whose initial diagnosis had been lymphoid malignancy. To the best of our knowledge, this is only the second report of using single-photon emission computed tomography (SPECT) to diagnose spinal tophus. We retrospectively reviewed the medical records, operative reports and radiographic imaging studies of a single patient. A 26-year-old man with severe tophaceous gout presented with a 4-month history of progressive weakness and dyschesia of both lower extremities. Coronal bone slices evaluated by SPECT indicated increased methylene diphosphonate uptake in the T9 and T10 pedicles. Pathology assessment revealed areas of amorphous substance containing urate crystals surrounded by inflammatory cells. The diagnosis was gouty tophus. The position of the spinal tophus may be related to the 'S' type of spinal anatomical structure. Obesity and inactivity may be the two risk factors for spinal tophus. Every effort should be made to lower the serum uric acid level by maximizing the pharmacological regimen. We believe that laminectomy can effectively relieve spinal cord compression. It also improves the long-term prognosis for spinal gouty tophus. SPECT may be a viable method for differentiating spinal gout and a malignant tumor.

Endoscopic Resection of Gouty Tophus of the Patellar Tendon

Tophaceous deposition of tendon can result in spontaneous patellar tendon rupture. Surgical therapy may be needed to control symptoms and prevent tendon rupture. Open debridement of the lesion requires a lengthy incision over the lesion; this may result in symptomatic scar adhesion of the patellar tendon or an unhealed wound with persistent tophaceous discharge. Moreover, the other part of the patellar tendon cannot be examined through the incision. We describe a technique for endoscopic resection of a gouty tophus of the patellar tendon. It has the advantage of small incisions away from the lesion and tendon and minimizes wound problems. The whole patellar tendon can be examined endoscopically.

Carpal Tunnel Syndrome Associated with Tophaceous Deposition in Flexor Digitorum Tendons

Carpal tunnel syndrome is the most common peripheral entrapment neuropathy. We report on the first Korean case of carpal tunnel syndrome induced by tophaceous deposition in flexor digitorum tendons of a patient with chronic gout. A 63-year-old male suffered from numbness, decreased sensation over both median nerve distribution, and weakness of thenar muscle for 3 years. Physical examinations revealed positive Tinel’s sign and Phalen’s test and thenar qjmuscle atrophy was found on both hands. In nerve conduction study, there was no action potential of the sensory and motor of the bilateral median nerve. Ultrasonography showed increased cross-sectional area of median nerve due to tophaceous deposition in flexor digitorum tendons in the carpal tunnel. Dual-energy computed tomography showed diffuse multifocal green color coding tophaceous deposition within the carpal tunnel. His neuropathic symptoms improved after injection of triamcinolone into the carpal tunnel and administration of oral medication including non-steroidal anti-inflammatory drugs and colchicine. (J Rheum Dis 2015;22:29-33)

A Rare Case of Tumoral Calcium Pyrophosphate Dihydrate Crystal Deposition Disease of the Wrist Joint.

Introduction. Tumoral calcium pyrophosphate dihydrate (CPPD) crystal deposition disease (CPPDCD), also known as tophaceous calcium pyrophosphate deposition disease (CPDD), is a tumorlike lesion, and it should be distinguished from usual CPDD that causes severe joint inflammation and arthralgia. A case of tumoral CPPDCD of the wrist joint that required differentiation from synovial osteochondromatosis is described. Case Presentation. The patient was a 78-year-old woman with a 5-year history of nodular lesions at the right wrist that had gradually increased in size. An excisional biopsy and a histological examination of the excised nodular lesions by hematoxylin and eosin (H&E) staining were performed, demonstrating numerous polarizable, rhabdoid, and rectangular crystals, surrounded by fibroblasts, macrophages, and foreign body-type giant cells, consistent with tumoral CPPDCD. Conclusion. Tumoral CPPDCD, especially at the wrist joint, is rare, and, to the best of our knowledge, only 2 articles have been published. This case seems to need further follow-up for recurrence, because tumoral CPPDCD may recur after complete or incomplete surgical excision.

Acute Comminuted Pathologic Fracture of a Hallucal Sesamoid with Tophaceous Gout: A Case Report.

Fractures in the sesamoid bones may occur by direct trauma or repetitive overuse (stress fractures). Acute fracture of the hallucal sesamoids is seen most often with dislocation of the metatarsophalangeal joint after a high-energy injury1. A chronic stress fracture of the sesamoid bone is generally found in athletes and can be difficult to differentiate from other conditions that affect the hallucal sesamoids2. The optimal choice of treatment remains unclear3. In chronic tophaceous gout, urate deposition may occur in articular cartilage, subchondral membranes, joint capsules, and periarticular tissues. An isolated intraosseous tophaceous lesion in the hallucal sesamoids is rare4-7. We found only one previously published report describing a chronic stress fracture and nonunion of a hallucal sesamoid that was associated with tophaceous gout8. To our knowledge, there have been no previously published reports of an acute comminuted pathologic fracture of a hallucal sesamoid with a tophaceous deposit. We describe a rare case of an acute comminuted pathologic fracture with tophus of the fibular sesamoid in a young soldier with no history of gout or underlying systemic disorder. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A twenty-year-old soldier with no history of gout noted a painful disability of the right forefoot during a military march. The pain persisted for several days, and he was not able to bear weight in the standing position. He noted that he had experienced similar forefoot pain three years prior; he had also experienced similar symptoms several times before, but with less intensity. The pain increased during forced dorsiflexion of the …

SP0064 Imaging Biomarkers as A Useful Tool in Gout Disease

Conventional radiography can show characteristic features of gouty arthritis such as intraosseous cysts or large erosions with overhanging edges in an advanced tophaceous stage. For early diagnosis, however, conventional X-rays...