Neck pain: an unusual presentation of a common disease.

Department of Neuroradiology and Neuropathology, Hope Hospital, Salford, Manchester M6 8HD, UK.
British Journal of Radiology (Impact Factor: 1.53). 07/2006; 79(942):537-9. DOI: 10.1259/bjr/28763793
Source: PubMed
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    ABSTRACT: Tophaceous gout uncommonly affects the axial skeleton. The clinical presentations of gout of the spine range from back pain to quadriplegia. Gout that presents as back pain and fever may be difficult to distinguish from spinal infection. We present a case of a patient with tophaceous gout of the lumbar spine who was initially diagnosed with and treated for an epidural infection. The clinical and diagnostic features of tophaceous gout of the spine are reviewed. A 70-year-old man presented with a 2-day history of fever and back pain. A physical examination revealed that he had flank tenderness and evidence of polyarthritis affecting the elbows, knees, and right first metatarsophalangeal joint. A magnetic resonance imaging scan of the patient's lumbar spine showed an extensive area of abnormal gadolinium enhancement of the paramedian posterior soft tissues from L3 to S1 with an area of focal enhancement extending into the right L4-L5 facet joint. A laminectomy was performed at L4-L5, and a chalky white material in the facet joint was found eroding into the adjacent pars intra-articularis. Light and polarizing microscopy confirmed the presence of gouty tophus. No evidence of infection was found. Gouty arthritis of the spine is rare. Thirty-seven previous cases have been reported. When the clinical presentation includes acute back pain and fever, differentiation of spinal gout from spinal infection may be difficult. The clinical suspicion of spinal gout may lead to the correct diagnosis by a less invasive approach than exploration and laminectomy.
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    ABSTRACT: MR imaging is not routinely used for evaluation of tophaceous gout. However, gout may present clinically in an atypical, unusual, or confusing manner. A gouty tophus occasionally mimics an infectious or neoplastic process, and MR imaging may be obtained under these circumstances. The purpose of this study was to determine the MR imaging characteristics of intraosseous and soft-tissue tophi. We identified 13 MR imaging examinations performed during a 27-month period on nine patients with gouty arthritis. All were men 42-70 years old. T1-, proton density-, and T2-weighted spin-echo MR images were obtained for all the examinations. Nine examinations included contrast-enhanced MR images. The findings were then evaluated, as were the corresponding radiographs. Five patients presented with articular involvement, three patients with an isolated soft-tissue mass, and one patient with persistent soft-tissue swelling. The duration of symptoms ranged from 3 months to more than 20 years. Nearly all the tophi were of intermediate signal intensity on T1-weighted images. On T2-weighted images, three sites revealed an overall increase in the signal intensity of the tophi, whereas 10 studies showed a heterogeneous decrease in signal intensity. All but one tophus showed homogeneous enhancement. Erosion of adjacent bone, synovial pannus, joint effusion, soft-tissue edema, and bone marrow edema were common associated findings. The MR appearance of tophi in patients with tophaceous gout is constant on T1- but quite variable on T2-weighted images. This variability in signal intensity could be related to calcium within a tophus. Tophaceous gout should be considered in the differential diagnosis when a mass reveals heterogeneously low to intermediate signal intensity, particularly if the adjacent bone shows typical erosive changes or if other joints are involved. When faced with this situation, radiologists may find it helpful to obtain a further clinical history and recommend evaluating the patient's serum urate level.
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