Case Presentation:

Gout is a crystalline arthropathy characterized by the deposition of urate crystals in joints. Typically, it involves the first metatarsophalangeal joint (podagra), ankle, or knee joint, although other joints may be affected. Gout presents as an acute mono‐ or oligoarticular arthritis with warm, tense, dusky red overlying skin. Increased serum uric acid may be seen in 70% cases of acute gout. Gout occurs in men and postmenopausal women, and risk factors include diabetes, hypertension, chronic kidney disease, increased purine intake, alcohol, diuretic therapy, land owdose aspirin. Definitive diagnosis is made through arthrocentesis with polarized microscopic examination of the synovial fluid showing intracellular or extracellular needle‐shaped, negatively birefringent crystals.

Discussion:

A 61‐year‐old postmenopausal female with a history of moderate L4‐L5 central spinaJ canal stenosis and hypertension, presented with 3 weeks of severe right lower‐extremity pain, felt over the right hip, radiating to the right leg, and worsened on weight bearing. Multiple prior evalua‐lions in the emergency room for these symptoms revealed unremarkable x‐rays of the back, hips, and pelvis. Treatment with opiates and NSAIDs was ineffective. The patient was able to recall an isolated episode of possible podagra more than 10 years prior to her current events. On examination, flexion and extension of the right hip elicited slight tenderness, and point tenderness was noted over the right sacroiliac joint. A right knee effusion was detected. Laboratory examination was remarkable for a normal CBC and CMP, and her ESR (55 mm/Hg) and CRP (39 mg/L) were elevated along with a high serum uric acid level (10 mg/dL). On further investigation. MRI imaging revealed right‐sided sacroiliitis along with edema in the iliopsoas region. CT‐guided joint aspiration revealed large amounts of intra‐ and extracellular, negatively birefringent monosodium urate crystals along with prominent tophaceous formations. Infection was excluded. Diagnosis of chronic tophaceous gout with acule gouty sacroiliitis and a possible component of crystalline iliopsoas tendonitis was made. Patient refused intra‐articular steroid injection and was treated with systemic glucocorticoids. Uric acid‐lowering therapy with allopurinol was started on outpatient follow‐up.

Conclusions:

Characteristically, gout affects peripheral joints, and axial involvement is considered infrequent. Literature on axial gout is limited to case reports and case series. Reports suggest that axial radiographic involvement in gout is frequently underrecognized, as it may remain subclinical. Patients with acute gouty sacroiliitis may present with pain referred to the thigh, hip, or back, and crystalline iliopsoas tendonitis may further restrict hip movement, as seen in our case. Acule gouty arthritis should be considered in patients presenting with sacroiliac joint pain, particularly if they have a history of gout or risk factors for this form of rheumatism.

Author Disclosure:

M. Nabeel, Department of internal Medicine, University of Illinois at Urbana‐Champaign, IL first author; A. Verma, Department of Internal Medicine, University of Illinois At Urbana‐Champaign, IL, colleague; Y. Yang, Department of Internal Medicine, University of Illinois at Urbana‐Champaign, IL, colleague; H. Castro‐Rueda, Department of Internal Medicine, University of Illinois at Urbana‐Champaign, IL/Department of Rheumatology, Carle Foundation Hospital, Urbana, IL, attending physician.