Presentation
Pain and swelling in both knees and small joints of hands from four years.
Patient Data
There is evidence of advanced erosive polyarthritis with extensive periarticular lytic bone lesions involving the MCP and PIP joints with associated large soft-tissue masses. Note the overhanging edges and sclerotic margins. Erosions are seen in multiple carpal bones. Erosive changes are also noted in the distal ulna on both sides with adjoining soft tissue masses.
Prominent lytic lesions are seen in the patella and tibial tuberosities bilaterally. Radiodense masses are seen in the suprapatellar fossa bilaterally and adjoining the right tibial tuberosity.
Case Discussion
This young patient has painful swelling in hands and knees from four years. He has chronic hyperuricemia which is poorly controlled despite treatment. Diagnosis of gout had been made by joint aspirate. He is also suffering from hypertension which started around the same time as gout. He denies a family history of similar condition.
He is on allopurinol and colchicine for gout and amlodipine for hypertension. The rheumatologist is considering starting him on pegloticase.
Gout is a crystal deposition disease caused by deposition of monosodium urate crystals mainly in the joints. The crystals can also be deposited in tendons and nerves. The first metatarsal-phalangeal joint is the classic site of involvement. Knees are occasionally involved but hand involvement is uncommon.
The diagnosis can be made by visualization of negative birefringent crystals in the joint aspirate.
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