Tophaceous gout of the lumbar spine in a renal transplant patient: a case report and literature review

doi:10.1016/S0720-048X(00)00214-X

European Journal of Radiology

Volume 36, Issue 3, 1 December 2000, Pages 123-125

https://doi.org/10.1016/S0720-048X(00)00214-X Get rights and content

Abstract

Tophaceous gout of the spine is rare. We report the case of a 27-year-old male, renal transplant recipient, who presented with an acute onset of lower back pain. Radiological, biochemical and histo-pathological findings confirmed a diagnosis of tophaceous gout of the lumbar spine. We present the case history with the radiological findings and discuss the literature.

Introduction

Gout is a pathological condition resulting from monosodium urate or uric acid crystal deposition. It is predominantly idiopathic but can also be associated with other disorders such as chronic renal failure, myeloproliferative disease and drug therapy. Patients with inadequately treated acute gout may develop chronic tophaceous gout with nodular deposition of calcium urate in synovium, soft tissue and subchondral bone [1].

Tophaceous gout of the spine is rare. We report the first described case of a renal transplant recipient developing tophaceous gout of the lumbar spine and discuss the literature.

Section snippets

Case report

A 27-year-old male patient presented to the emergency room with a 24-hr history of right sided lower back pain. He had a background history of IgA nephropathy and hypertension and had been dialysis dependent until he received a cadaveric renal transplant in 1990. The transplant was functioning poorly with biopsy evidence of chronic rejection. He was maintained on dual anti-rejection therapy of cyclosporin A and oral corticosteroids. The patient had a documented history of non-tophaceous gout

Discussion

Renal transplant recipients are at an increased risk of developing gout [1]. Additional risk factors for the development of gout in this patient include a positive family history, chronic renal failure and cyclosporin A therapy. West et al. showed an 11.8% incidence of gout in 211 post-renal transplant patients receiving corticosteroids and Cyclosporin A [2].

Urate deposition in soft tissues is a well documented feature of gout, particularly in para-articular regions and in articular cartilage

Conclusion

Although involvement of the lumbar spine in gout is rare the diagnosis should be considered in high risk patients such as renal transplant recipients in whom there is an appropriate clinical history of backpain or related symptomatology. We describe the first reported case of tophaceous gout of the spine in a renal transplant recipient.

References (8)

C. West et al.
The incidence of gout in renal transplant recipients
Am. J. Kidney Dis.
(1987)
M. Vervaeck et al.
Sudden hypotonic paraparesis caused by tophaceous gout of the lumbar spine
Clin. Neurol. Neurosurg.
(1991)
S. Rozenberg et al.
What remains of gout in 1993?
Rev. Prat.
(1994)
J. Varga et al.
Tophaceous gout of the spine in a patient with no peripheral tophi: case report and review of the literature
Arthritis Rheum.
(1985)

There are more references available in the full text version of this article.

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A gota axial pode afetar todos os segmentos da coluna vertebral. Ela se manifesta como dor nas costas, dor associada com sintomas neurológicos, e como comprometimento neurológico sem dor em 17,9%, 75,8% e 4,2% dos casos, respectivamente. Essas manifestações foram a primeira apresentação da gota em muitos pacientes. Embora radiografias, bem como tomografia computadorizada e especialmente ressonância magnética, possam ser muito sugestivos, análises histopatológicas, citológicas e pesquisa de cristais são o padrão ouro de diagnóstico. Na maioria dos casos que envolveram manifestações neurológicas, o paciente foi submetido à cirurgia, levando a resultados satisfatórios. Há, no entanto, alguns relatos de recuperação total após o tratamento clínico habitual para gota, o que sugere que esse tratamento pode ser a opção inicial para os indivíduos com histórico de gota e sinais radiológicos de envolvimento axial.
Axial gout can affect all segments of the spine. It is manifested as back pain, as pain associated with neurological symptoms, and as neurological impairment without pain in 17.9%, 75.8% and 4.2% of cases, respectively. These manifestations were the first presentation of gout in many patients. Although x-rays as well as computed tomography and especially magnetic resonance scans can be very suggestive, histopathological, cytological and crystal analyses are the diagnostic gold standard. In most cases involving neurological manifestations, the patient underwent surgery, leading to satisfactory results. There are, however, some reports of full recovery following the usual clinical treatment for gout, suggesting that such treatment may be the initial option for those subjects with a history of gout and radiological findings of axial involvement
The Broad Spectrum of Urate Crystal Deposition: Unusual Presentations of Gouty Tophi
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Citation Excerpt :
In fact, visible tophi have been seen in transplant patients before any other gouty symptoms have been reported. Although typical sites of gout are often seen in transplant recipients, more unusual sites such as the finger pads, within the patella, at entheses, at the costochondral junction, sacroiliac joints, and spine have all been reported (91-97). Anti-inflammatory and immunosuppressant medications taken to prevent transplant rejection, such as corticosteroids, can mask acute gouty symptoms and these patients can present with tophi as their initial manifestation of gout.
Gout is typically described as an inflammatory arthropathy that affects the peripheral joints. Our aim was to describe atypical and rare clinical presentations of gouty tophi to help increase physician awareness and aid in patient care.
The relevant English literature of unusual gout manifestations was searched using the keywords gout, toph*, monosodium urate, uric acid, unusual, and rare. Well-described case reports, case series, and review articles were evaluated and included, if relevant, in the literature review.
Review of the literature revealed many unusual manifestations of gouty tophi involving the head and neck, skin, viscera, bones, tendons, ligaments, nerves, and axial skeleton. Transplant recipients, women, and elderly people are particularly susceptible to developing tophi. Furthermore, gout can cause diagnostic dilemmas, as it can be a great mimicker of and can coexist with infection, malignancy, and other connective tissue diseases. Imaging modalities can help detect tophi in atypical locations.
Tophi can present in unexpected locations, even as the first sign of gout, and vigilance is required when unusual symptoms or signs occur in a patient with gout.
Tophaceous gout causing stenosis of T11-T12
2008, Medicina Clinica

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Case reportTophaceous gout of the lumbar spine in a renal transplant patient: a case report and literature review

Abstract

Introduction

Section snippets

Case report

Discussion

Conclusion

Am. J. Kidney Dis.

Clin. Neurol. Neurosurg.

What remains of gout in 1993?

Rev. Prat.

Tophaceous gout of the spine in a patient with no peripheral tophi: case report and review of the literature

Arthritis Rheum.

Case report
Tophaceous gout of the lumbar spine in a renal transplant patient: a case report and literature review