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Year : 2018  |  Volume : 33  |  Issue : 2  |  Page : 158-160  

Lumbar Gout Tophus Mimicking Epidural Abscess with Magnetic Resonance Imaging, Bone, and Gallium Scans


1 Department of Nuclear Medicine, University Hospital Infanta Cristina, Badajoz, Spain
2 Department of Orthopedic Surgery, University Hospital Ramón Y Cajal, Madrid, Spain
3 Department of Orthopaedic Surgery, University Hospital Infanta Cristina, Badajoz, Spain

Date of Web Publication15-Mar-2018

Correspondence Address:
Dr. Justo Serrano Vicente
Department of Nuclear Medicine, University Hospital Infanta Cristina, Badajoz
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_139_17

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   Abstract 


Gout is a common metabolic disorder, typically diagnosed in peripheral joints. Tophaceous deposits in lumbar spine are a very rare condition with very few cases reported in literature. The following is a case report of a 52-year-old patient with low back pain, left leg pain, and numbness. Serum uric acid level was in normal range. magnetic resonance imaging, bone scan, and gallium-67 images suggested an inflammatory-infectious process focus at L4. After a decompressive laminectomy at L4–L5 level, histological examination showed a chalky material with extensive deposition of amorphous gouty material surrounded by macrophages and foreign-body giant cells (tophaceous deposits).

Keywords: Bone scintigraphy, gallium-67, gout tophus, low back pain, lumbar spine, magnetic resonance imaging


How to cite this article:
Vicente JS, Gómez AL, Moreno RL, Infante Torre JR, Bernardo LG, Rayo Madrid JI. Lumbar Gout Tophus Mimicking Epidural Abscess with Magnetic Resonance Imaging, Bone, and Gallium Scans. Indian J Nucl Med 2018;33:158-60

How to cite this URL:
Vicente JS, Gómez AL, Moreno RL, Infante Torre JR, Bernardo LG, Rayo Madrid JI. Lumbar Gout Tophus Mimicking Epidural Abscess with Magnetic Resonance Imaging, Bone, and Gallium Scans. Indian J Nucl Med [serial online] 2018 [cited 2019 Dec 8];33:158-60. Available from: http://www.ijnm.in/text.asp?2018/33/2/158/227495



We present a 52-year-old male was admitted at our hospital with acute low back and left leg pain and numbness and fever in the evening hours of 2 weeks duration. His prior medical history included obesity, hay fever, and dust allergy. Physical examination revealed no fever, clear lungs, and normal heart sounds. Biochemical findings showed only an elevated glucose level and C-reactive protein level (18.3 mg/dl, [normal range: 0.1–0.6]). Serum uric acid level and all other laboratory test were in a normal range. Chest radiographs were unremarkable. Lumbar spine plain radiographs showed faint degenerative facet arthropathy on vertebral bodies that did not explain the symptomatology. A lumbar magnetic resonance imaging (MRI) was requested showing lumbar posterior epidural collection L3–L4, extending into spinal canal, resembling an epidural and facet abscess with paraspinal soft-tissue collection [Figure 1]. This abnormal structure showed hypointense signal in T1- [Figure 1]a and T2- [Figure 1]b weighted sequences. Intense enhancement was showed by this collection and adjacent soft tissues after administration of contrast medium [Figure 1]c. Blood cultures were sterile and serological test for  Brucella More Details, Borrelia,  Salmonella More Details, hepatitis B and C viruses ( BHV and CHV) were negative. Mantoux was also negative.
Figure 1: Lumbar magnetic resonance imaging of sagittal slices with different signals T1-weighted (a), T2-weighted (b) and after administration of gadolinium (c)

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Images of bone and gallium 67 were requested to discard a discitis. In the [Figure 2], we can see whole-body bone [Figure 2]a and [Figure 2]b and gallium scans [Figure 2]c and [Figure 2]d with slight pathological uptake at L4 on bone scintigraphy but intense in gallium67 image. In addition, we can see serial uptakes in the costovertebral and intervertebral junctions that suggested a diffuse idiopathic skeletal hyperostosis (DISH or Forestier disease) that could contribute to the back pain. In the right side of [Figure 2]e, we show tomographic transaxial, sagittal, and coronal slices of gallium 67 single photon emission computed tomography (SPECT) that locate the uptake at the posterior aspects of L4. Both studies suggested an inflammatory-infectious focus at L4. Descompressive laminectomy at L4–L5 level was performed and revelead a white cheesy material with spinal canal stenosis and dural sac compression.
Figure 2: Anterior and posterior views of bone (a and b) and gallium (c and d) whole body scans, anterior and posterior views, in the left half of the figure showing pathological uptake at L4. In the right half of the figure (e), we show axial, sagittal, and coronal slices of a gallium single-photon emission computed tomography showing focal pathological uptake at the posterior aspects of L4

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Histological results from the L3 to L4 disc showed chalky material with extensive deposition of aggregates of urate crystals surrounded by an inflammatory reaction including multinucleated giant cells [Figure 3]. This entity has occasionally been reported in the spine. Most patients diagnosed of spinal gout are previously symptomatic due to chronic tophaceous gout. Nevertheless, but it could be the primary presentation in asymptomatic patients, which usually have increased uric acid levels in serum, mimicking an infectious discitis.[3] These characteristics make patient's history crucial for diagnosis, mainly if we consider that radiographic, MRI, and SPECT features of spinal gout are not specific and may deceptively mimic a degenerative, inflammatory, infectious, or neoplastic process.[4],[5] Definitive diagnosis relies on the demonstration of needle-shaped crystals negatively birefringent under polarized red light.[6] The patient was discharged from the hospital asymptomatic remaining in stable condition at 2 years follow-up. Lumbar MRI revealed good spinal stability and no evidence of new abnormalities. Gout remains as a very difficult diagnosis entity when located in axial skeleton. Despite the sophisticated and developed current neuroimaging diagnostic techniques, patient's history is crucial and extremely important for diagnosis, being normouricemia, not a reliable finding for exclusion.
Figure 3: Microscopic histological examination of the samples showing chalky material with extensive deposition of amorphous gouty material surrounded by macrophages and foreign-body giant cells

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Miller JD, Percy JS. Tophaceous gout in the cervical spine. J Rheumatol 1984;11:862-5.  Back to cited text no. 1
    
2.
Jegapragasan M, Calniquer A, Hwang WD, Nguyen QT, Child Z. A case of tophaceous gout in the lumbar spine: A review of the literature and treatment recommendations. Evid Based Spine Care J 2014;5:52-6.  Back to cited text no. 2
    
3.
Paquette S, Lach B, Guiot B. Lumbar radiculopathy secondary to gouty tophi in the filum terminale in a patient without systemic gout: Case report. Neurosurgery 2000;46:986-8.  Back to cited text no. 3
    
4.
Suk KS, Kim KT, Lee SH, Park SW, Park YK. Tophaceous gout of the lumbar spine mimicking pyogenic discitis. Spine J 2007;7:94-9.  Back to cited text no. 4
    
5.
Chang IC. Surgical versus pharmacologic treatment of intraespinal gout. Clin Orthop Relat Res 2005;433:106-10.  Back to cited text no. 5
    
6.
Gentili A. The advanced imaging of gouty tophi. Curr Rheumatol Rep 2006;8:231-5.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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