Common sites of monosodium urate (MSU) deposition include the first metatarsophalangeal joint, ears, fingers, and olecranon bursa.1 The nose is an unusual location for gout.
A 62-year-old male individual presented to the emergency department with acute bilateral hand pain. He has a background of untreated chronic tophaceous gout, type 2 diabetes mellitus, ischemic heart disease, and hypertension. He did not tolerate allopurinol in the past due to development of a rash. He last attended the rheumatology clinic 8 years ago. He was noted to have a firm mass on the tip of the nose and a sinus tract with a history of white chalky discharge (Figure 1).
Frontal view of nasal mass with sinus tract at presentation.
A dual-energy computed tomography (DECT) scan of the facial bones demonstrated MSU deposition within the tip of the nose, at the quadrangular cartilage, and at the nasal bone (Figure 2). There was also MSU signal intensity surrounding the base of the dens in the medial atlantoaxial joint.
(A) Virtual DECT reconstruction demonstrating MSU deposition in soft tissue at the tip of the nose, inferior margin of quadrangular cartilage, and junction between nasal bone and superior corner of the quadrangular cartilage. There is MSU signal surrounding the base of the dens (yellow arrow). (B) DECT axial view of facial bones demonstrates bony erosions present at the nasal bone (green arrow). (C) DECT sagittal view demonstrating MSU deposition at the tip of the nose. DECT: dual-energy computed tomography; MSU: monosodium urate.
Blood tests revealed elevated C-reactive protein at 39 mg/L (reference interval [RI] < 5 mg/L). His uric acid was 0.59 mmol/L (RI 0.2-0.42 mmol/L). He was treated for polyarticular gout flare, and his hand pain improved with a course of prednisone. He was commenced on febuxostat and prophylactic colchicine. His hand function improved to baseline after 2 weeks. Uric acid after 2 months was 0.5 mmol/L, but there was no obvious change in nasal mass.
Although polarized light microscopy visualization of MSU crystals remains the diagnostic gold standard for gout, it may not always be possible due to logistical or patient factors.2 In this case, because the patient declined a biopsy, a positive DECT scan showing characteristic findings for gout was useful in establishing a diagnosis of nasal gout, as per European Alliance of Associations for Rheumatology (EULAR) recommendations.3 Despite a high accuracy in detecting MSU in peripheral joints, not all MSU signal intensity on DECT represents actual MSU deposition with artifacts being reported in the skin and nose.4,5
This case raises 2 important considerations: (1) The diagnostic accuracy of DECT in assessing cartilage, in particular the quadrangular cartilage, is not well established, necessitating a tissue biopsy to prove MSU deposition; and (2) DECT scan interpretation requires trained professionals to distinguish true MSU deposition from artifacts, thereby minimizing false-positive results, in line with EULAR recommendations.3
Footnotes
CONTRIBUTIONS
PX: writing - original draft, conceptualization; MO: conceptualization; GH: conceptualization; DM: writing - review & editing.
FUNDING
The authors declare no funding or support for this work.
COMPETING INTERESTS
The authors declare no conflict of interest relevant to this article.
ETHICS AND PATIENT CONSENT
Ethics review board approval was not required according to the authors’ institution. The article has been submitted with written consent of the patient.
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