http://informahealthcare.com/mor ISSN 1439-7595 (print), 1439-7609 (online) Mod Rheumatol, 2014; 24(6): 1026–1027 © 2014 Japan College of Rheumatology DOI: 10.3109/14397595.2013.877326
RAPID COMMUNICATION
Spondylodiscitis and Achilles tendonitis due to gout Yoshinori Taniguchi, Tatsuki Matsumoto, Makoto Tsugita, Shimpei Fujimoto, and Yoshio Terada
Mod Rheumatol Downloaded from informahealthcare.com by University of Sydney on 03/13/15 For personal use only.
Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi, Japan Abstract
Keywords
The patient, a 62-year-old man with a 3-year history of hyperuricemia, presented with severe neck pain, Achilles enthesopathy and polyarthralgia. He consumed alcohol heavily. The biochemical profile was normal except for elevated levels of CRP (3.6 mg/dl; normal ⬍ 0.3), uric acid (UA) (10.9 mg/dl; normal 2.5–7.5) and creatinine (1.7 mg/dl; normal 0.5–1.0). Bone scintigraphy showed polyarthritis at the right elbow, wrist and bilateral first MTP joints. Notably, bone scintigraphy with computed tomography also revealed spondylodiscitis of C5-C6, which was confirmed by MRI, and left Achilles tendonitis. Moreover, left Achilles tendonitis was also confirmed by ultrasonography, indicating enthesitis with low-echoic lesion and calcification. Needle aspiration yielded a white viscous liquid, with numerous urate crystals identified on polarized light microscopy. He was diagnosed with gouty arthritis associated with spondylodiscitis and Achilles tendonitis. After the treatment with allopurinol, colchicine and predonisolone, his symptoms were improved, and serum CRP and UA levels were normalized. The cervical spine and Achilles tendon are rare and notable sites of involvements in gout, and differential diagnosis of gouty arthritis from spondyloarthritis, rheumatoid arthritis, tumor, pseudogout, and infection is necessary. When the patient was noted to have neck pain and Achilles enthesopathy, we should always recognize gouty arthritis.
Achilles tendonitis, gout, scintigraphy, spondylodiscitis, ultrasonography
Inflammatory arthritis is caused by several disorders including rheumatoid arthritis, spondyloarthritis, gout, pseudogout, infection, and connective tissue diseases. Of these, gout is the most common cause. The prevalence of gout is rapidly increasing in the general population [1,2]. New diagnostic imaging methods for gouty arthritis have been investigated. Recently, several reports have demonstrated the safe and accurate identification of multiple sites of involvement in patients with gout using ultrasonography (US), magnetic resonance imaging (MRI), and computed tomography (CT) [3,4]. Here, we report a rare and informative case of gout associated with spondylodiscitis and Achilles tendonitis. A 62-year-old man, with a 3-year history of hyperuricemia, presented with severe neck pain, Achilles enthesitis, and polyarthralgia. He was a heavy drinker, consuming two to three alcoholic beverages per day. His biochemical profile was normal except for elevated levels of C-reactive protein (3.6 mg/dl; normal ⬍ 0.3), uric acid (10.9 mg/dl; normal 2.5–7.0), and creatinine (1.7 mg/ dl; normal 0.5–1.0). Plain X-ray showed no calcification in each joint. Bone scintigraphy (Figure 1A) showed polyarthritis at the right elbow and wrist, and bilateral first metatarsophalangeal (MTP) joint. Notably, bone scintigraphy with CT also revealed spondylodiscitis with bone erosion of C5-C6 (Figure 1A and B), which was confirmed by MRI (Figure 1C). Bone scintigraphy with CT also revealed left Achilles tendonitis (Figure 1A). This was confirmed by US, which indicated enthesitis with a low-echoic
Correspondence to: Yoshinori Taniguchi, Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kohasu, Oko-Cho, Nankoku, Kochi 783-8505, Japan. Tel: ⫹ 81-88-8802427. Fax: ⫹ 81-88-880-2428. E-mail: [email protected]
History Received 18 October 2013 Accepted 14 December 2013 Published online 4 February 2014
lesion and calcification (Figure 1D). Needle aspiration yielded a white viscous liquid, with numerous urate crystals detected by polarized light microscopy (Figure 1E). The patient was diagnosed with gouty arthritis associated with spondylodiscitis and Achilles tendonitis/enthesitis. Treatment with daily oral prednisolone (PSL) (15 mg) and colchicine (0.5 mg) was initiated, and after acute attack was followed by daily oral febuxostat (10 mg). PSL was tapered and stopped after 3 weeks. Following treatment, the patient’s symptoms improved and serum C-reactive protein and uric acid levels normalized, and he was discharged without further complications. Recent report demonstrated that tendons are commonly affected by monosodium urate crystal deposition in patients with tophaceous gout, and that the Achilles tendon is the most commonly involved tendon/ligament site (39.1% of all Achilles tendons) by dual-energy CT study [5]. Another US-controlled study showed that Achilles enthesitis was more frequent in hyperuricemic than normouricemic individuals (15% vs. 1.9%) [6]. However, spinal gout is not as rare as previously thought. Recent reports demonstrated that lesions of the spine, including the discs, vertebral bodies, and facet joints, were present in 35% of gout cases [7,8]. Consistent with this report, spondylodiscitis and Achilles tendonitis due to gout often mimic heterogeneous spinal conditions and peripheral enthesitis such as spondyloarthritis. The cervical spine and Achilles tendon are informative and notable sites of involvement in gout, and this possibility indicates the need to diagnose gouty arthritis from spondyloarthritis, rheumatoid arthritis, tumor, pseudogout, and infection. In addition, bone scintigraphy with CT helps in evaluating the extent of gouty arthritis. Gouty arthritis should always be considered in patients with neck pain and Achilles enthesitis.
Spondylodiscitis and Achilles tendonitis due to gout 1027
DOI 10.3109/14397595.2013.877326
Mod Rheumatol Downloaded from informahealthcare.com by University of Sydney on 03/13/15 For personal use only.
(A)
(B)
(D)
(C)
(E)
Figure 1. (A) Evaluation of widespread inflammatory sites of involvement by bone scintigraphy; (B) C5-C6 spondylodiscitis detected using bone scintigraphy with CT; (C) C5-C6 spondylodiscitis detected by MRI (fat-suppressed T2 weighted imaging) of the cervical spine; (D) Achilles enthesitis with low-echoic lesion and calcification detected by US; (E) Spiked rods of numerous monosodium urate crystals detected by polarized light microscopy from synovial fluid and tissue.
Acknowledgments We received no financial support for this study.
Conflict of interest None.
References 1. Zhu Y, Pandya BJ, Choi HK. Prevalence of gout and hyperuricemia in the US general population: the National Health and Nutrition Examination Survey 2007–2008. Arthritis Rheum. 2011;63(10):3136–41. 2. Richette P, Bardin T. Gout. Lancet. 2010;375(9711):318–28. 3. Girish G, Melville DM, Kaeley GS, Brandon CJ, Goyal JR, Jacobson JA, Jamadar DA. Imaging appearances in gout. Arthritis. 2013;2013:673401.
4. Girish G, Glazebrook KN, Jacobson JA. Advanced imaging in gout. Am J Roentgenol. 2013;201(3):515–25. 5. Dalbeth N, Kalluru R, Aati O, Horne A, Doyle AJ, McQueen FM. Tendon involvement in the feet of patients with gout: a dual-energy CT study. Ann Rheum Dis. 2013;72(9):1545–8. 6. Pineda C, Amezcua-Guerra LM, Solano C, Rodriguez-Henriquez P, Hernandez-Diaz C, Vargas A, et al. Joint and tendon subclinical involvement suggestive of gouty arthritis in asymptomatic hyperuricemia: an ultrasound controlled study. Arthritis Res Ther. 2011; 13(1):R4. 7. Wendling D, Prati C, Hoen B, Godard J, Vidon C, Godfrin-Valnet M, Guillot X. When gout involves the spine: five patients including two inaugural cases. Joint Bone Spine 2013;80(6): 656–9. 8. Ahmad I, Tejada JG. Spinal gout: a great mimicker. A case report and literature review. Neuroradiol J. 2012;25(5):621–5.
RAPID COMMUNICATION
Spondylodiscitis and Achilles tendonitis due to gout Yoshinori Taniguchi, Tatsuki Matsumoto, Makoto Tsugita, Shimpei Fujimoto, and Yoshio Terada
Mod Rheumatol Downloaded from informahealthcare.com by University of Sydney on 03/13/15 For personal use only.
Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi, Japan Abstract
Keywords
The patient, a 62-year-old man with a 3-year history of hyperuricemia, presented with severe neck pain, Achilles enthesopathy and polyarthralgia. He consumed alcohol heavily. The biochemical profile was normal except for elevated levels of CRP (3.6 mg/dl; normal ⬍ 0.3), uric acid (UA) (10.9 mg/dl; normal 2.5–7.5) and creatinine (1.7 mg/dl; normal 0.5–1.0). Bone scintigraphy showed polyarthritis at the right elbow, wrist and bilateral first MTP joints. Notably, bone scintigraphy with computed tomography also revealed spondylodiscitis of C5-C6, which was confirmed by MRI, and left Achilles tendonitis. Moreover, left Achilles tendonitis was also confirmed by ultrasonography, indicating enthesitis with low-echoic lesion and calcification. Needle aspiration yielded a white viscous liquid, with numerous urate crystals identified on polarized light microscopy. He was diagnosed with gouty arthritis associated with spondylodiscitis and Achilles tendonitis. After the treatment with allopurinol, colchicine and predonisolone, his symptoms were improved, and serum CRP and UA levels were normalized. The cervical spine and Achilles tendon are rare and notable sites of involvements in gout, and differential diagnosis of gouty arthritis from spondyloarthritis, rheumatoid arthritis, tumor, pseudogout, and infection is necessary. When the patient was noted to have neck pain and Achilles enthesopathy, we should always recognize gouty arthritis.
Achilles tendonitis, gout, scintigraphy, spondylodiscitis, ultrasonography
Inflammatory arthritis is caused by several disorders including rheumatoid arthritis, spondyloarthritis, gout, pseudogout, infection, and connective tissue diseases. Of these, gout is the most common cause. The prevalence of gout is rapidly increasing in the general population [1,2]. New diagnostic imaging methods for gouty arthritis have been investigated. Recently, several reports have demonstrated the safe and accurate identification of multiple sites of involvement in patients with gout using ultrasonography (US), magnetic resonance imaging (MRI), and computed tomography (CT) [3,4]. Here, we report a rare and informative case of gout associated with spondylodiscitis and Achilles tendonitis. A 62-year-old man, with a 3-year history of hyperuricemia, presented with severe neck pain, Achilles enthesitis, and polyarthralgia. He was a heavy drinker, consuming two to three alcoholic beverages per day. His biochemical profile was normal except for elevated levels of C-reactive protein (3.6 mg/dl; normal ⬍ 0.3), uric acid (10.9 mg/dl; normal 2.5–7.0), and creatinine (1.7 mg/ dl; normal 0.5–1.0). Plain X-ray showed no calcification in each joint. Bone scintigraphy (Figure 1A) showed polyarthritis at the right elbow and wrist, and bilateral first metatarsophalangeal (MTP) joint. Notably, bone scintigraphy with CT also revealed spondylodiscitis with bone erosion of C5-C6 (Figure 1A and B), which was confirmed by MRI (Figure 1C). Bone scintigraphy with CT also revealed left Achilles tendonitis (Figure 1A). This was confirmed by US, which indicated enthesitis with a low-echoic
Correspondence to: Yoshinori Taniguchi, Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kohasu, Oko-Cho, Nankoku, Kochi 783-8505, Japan. Tel: ⫹ 81-88-8802427. Fax: ⫹ 81-88-880-2428. E-mail: [email protected]
History Received 18 October 2013 Accepted 14 December 2013 Published online 4 February 2014
lesion and calcification (Figure 1D). Needle aspiration yielded a white viscous liquid, with numerous urate crystals detected by polarized light microscopy (Figure 1E). The patient was diagnosed with gouty arthritis associated with spondylodiscitis and Achilles tendonitis/enthesitis. Treatment with daily oral prednisolone (PSL) (15 mg) and colchicine (0.5 mg) was initiated, and after acute attack was followed by daily oral febuxostat (10 mg). PSL was tapered and stopped after 3 weeks. Following treatment, the patient’s symptoms improved and serum C-reactive protein and uric acid levels normalized, and he was discharged without further complications. Recent report demonstrated that tendons are commonly affected by monosodium urate crystal deposition in patients with tophaceous gout, and that the Achilles tendon is the most commonly involved tendon/ligament site (39.1% of all Achilles tendons) by dual-energy CT study [5]. Another US-controlled study showed that Achilles enthesitis was more frequent in hyperuricemic than normouricemic individuals (15% vs. 1.9%) [6]. However, spinal gout is not as rare as previously thought. Recent reports demonstrated that lesions of the spine, including the discs, vertebral bodies, and facet joints, were present in 35% of gout cases [7,8]. Consistent with this report, spondylodiscitis and Achilles tendonitis due to gout often mimic heterogeneous spinal conditions and peripheral enthesitis such as spondyloarthritis. The cervical spine and Achilles tendon are informative and notable sites of involvement in gout, and this possibility indicates the need to diagnose gouty arthritis from spondyloarthritis, rheumatoid arthritis, tumor, pseudogout, and infection. In addition, bone scintigraphy with CT helps in evaluating the extent of gouty arthritis. Gouty arthritis should always be considered in patients with neck pain and Achilles enthesitis.
Spondylodiscitis and Achilles tendonitis due to gout 1027
DOI 10.3109/14397595.2013.877326
Mod Rheumatol Downloaded from informahealthcare.com by University of Sydney on 03/13/15 For personal use only.
(A)
(B)
(D)
(C)
(E)
Figure 1. (A) Evaluation of widespread inflammatory sites of involvement by bone scintigraphy; (B) C5-C6 spondylodiscitis detected using bone scintigraphy with CT; (C) C5-C6 spondylodiscitis detected by MRI (fat-suppressed T2 weighted imaging) of the cervical spine; (D) Achilles enthesitis with low-echoic lesion and calcification detected by US; (E) Spiked rods of numerous monosodium urate crystals detected by polarized light microscopy from synovial fluid and tissue.
Acknowledgments We received no financial support for this study.
Conflict of interest None.
References 1. Zhu Y, Pandya BJ, Choi HK. Prevalence of gout and hyperuricemia in the US general population: the National Health and Nutrition Examination Survey 2007–2008. Arthritis Rheum. 2011;63(10):3136–41. 2. Richette P, Bardin T. Gout. Lancet. 2010;375(9711):318–28. 3. Girish G, Melville DM, Kaeley GS, Brandon CJ, Goyal JR, Jacobson JA, Jamadar DA. Imaging appearances in gout. Arthritis. 2013;2013:673401.
4. Girish G, Glazebrook KN, Jacobson JA. Advanced imaging in gout. Am J Roentgenol. 2013;201(3):515–25. 5. Dalbeth N, Kalluru R, Aati O, Horne A, Doyle AJ, McQueen FM. Tendon involvement in the feet of patients with gout: a dual-energy CT study. Ann Rheum Dis. 2013;72(9):1545–8. 6. Pineda C, Amezcua-Guerra LM, Solano C, Rodriguez-Henriquez P, Hernandez-Diaz C, Vargas A, et al. Joint and tendon subclinical involvement suggestive of gouty arthritis in asymptomatic hyperuricemia: an ultrasound controlled study. Arthritis Res Ther. 2011; 13(1):R4. 7. Wendling D, Prati C, Hoen B, Godard J, Vidon C, Godfrin-Valnet M, Guillot X. When gout involves the spine: five patients including two inaugural cases. Joint Bone Spine 2013;80(6): 656–9. 8. Ahmad I, Tejada JG. Spinal gout: a great mimicker. A case report and literature review. Neuroradiol J. 2012;25(5):621–5.
