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Tophaceous Gout of Lumbar Spine with Fever Mimicking Infection

(A) Computed tomography showing an ill-defined and erosive lesion in the L4 facet joint. (B) Magnetic resonance imaging T1-weighted images showing disseminated and extensive hypointense foci on L3-5 facet joints and pedicles. (C) Magnetic resonance imaging T2 fat saturation image showing numerous hyperintense and oval masses within sacrospinal muscle. (D) Homogeneous peripheral enhancement after the intravenous administration of gadolinium for the masses. (E) Plain radiograph of tophaceous enthesopathy of the left foot. (F) Plain radiograph of tophaceous enthesopathy of the bilateral anterior inferior iliac spine, greater trochanter, and lesser trochanter. (The arrows denote the lesions.)

A 56-year-old man was admitted with complaints of low back pain and fever lasting for about 2 months. He had a 10-year history of intermittent gouty arthritis in his feet, which was being treated with colchicine, with the most recent attack occurring 12 months before.

Assessment

On physical examination, his body temperature was 38.5°C. His peripheral joints showed no redness, swelling, warmth, or tenderness. A marked right paraspinal tenderness and movement limitation on lumbar spine without any neurologic deficits were detected. Conventional radiographs of lumbar spine revealed moderate degenerative changes but no definitive bony erosions. Computed tomography (CT) showed ill-defined and erosive lesions on the bilateral L3-5 facet joints and low-density masses around the right L5 facet joint. Magnetic resonance imaging (MRI) T1-weighted images showed disseminated and extensive hypointense foci on L3-5 facet joints and pedicles. MRI T2-weighted images and fat saturation images showed numerous hyperintense foci within sacrospinal muscle suggesting small abscesses from the erosive facet joints. Many oval masses were significantly revealed on the coronal plane. After the intravenous administration of gadolinium, the masses demonstrated homogeneous peripheral enhancement. No spinal cord compression was found.

Laboratory studies revealed erythrocyte sedimentation rate 56 mm/hour (normal, <20 mm/hour) and C-reactive protein 35 mg/L (normal, <8 mg/L). His white cell count was normal, and serum urate was 410 μmoL/L (normal, 149-417 μmoL/L). His HLA-B27 test was negative.

Diagnosis

With the impression of spinal infection, a fine-needle aspiration biopsy for abscess was performed bare handed at the patient’s bedside with the patient under local anesthesia; bacteriologic tests for puncture fluid did not support infections such as pyogenic, tuberculosis, or brucella spondylitis. The patient was empirically started on broad-spectrum antibiotics; however, his back pain and fever persisted. Moreover, he presented with tenderness on his left calcaneal tuberosity and bilateral hip joints after day 10 of his hospital stay. Radiographs of his left ankle and pelvis showed enthesopathy of the left calcaneal tuberosity, bilateral anterior inferior iliac spine, greater trochanter, and lesser trochanter (Figure 1).

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-De-an Qin, MD, Jie-fu Song, MD, Xiao-fang Li, MD, Yan-yan Dong, MD

This article originally appeared in the September issue of The American Journal of Medicine.

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