- Email: [email protected]
Tophaceous lumbar gout mimicking an epidural abscess
216
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 2 • March 1998
acidosis, and may have enabled the avoidance of intubation and mechanical ventilation. Studies are needed to evaluate the effect of heliox therapy on the prognosis of severe acute COPD exacerbation in the emergency department. PATRICKGERBEAUX,MD ALAINBOUSSUGES,MD DOMINIQUETORRO,MD PHILIPPEJEAN, MD
Service d'Accueil et d' Urgences H&pital Conception Marseille, France
References 1. Gluck EH, Onorato DJ, Castriotta R: Helium-oxygen mixtures in intubated patients with status asthmaticus and respiratory acidosis. Chest 1990;98:693-698 2. PolitoA, Fessler H: Heliox in respiratory failure from obstructive lung disease. N Engl J Med 1995;332:192-193 3. Swida DM, Montenegro HD, Goldman MD, et al: Heliumoxygen breathing in severe chronic obstructive pulmonary disease. Chest 1985;87:790-795
TOPHACEOUS LUMBARGOUT MIMICKINGAN EPIDURAL ABSCESS To the Editor:--The diagnosis of gout is rarely difficult in the patient with a known history of gout and an arthritide involving the first metatarsal, tarsometatarsal, or interphalangeal joints. Likewise, the diagnosis is also usually considered in patients with these symptoms and no known history of gout. However, in patients with arthritides not involving these articulations, the diagnosis may be less likely, particularly if the patient has a questionable o1"unknown history of gout. Although included in the differential diagnosis for patients presenting with back pain, spinal involvement with gout is relatively rare. Only 19 such cases exist in the English medical literature to our knowledge. We report the case of a patient who presented to the emergency department with low back pain and who was suspected of having an epidural abscess, and whose symptomatology was subsequently proven to result from lumbar tophaceous gout. Report of a case. A 68-year-old African-American man with a history of congestive heart failure, hypertension, chronic renal insufficiency, gout, and atrial fibrillation presented to our emergency department on 3/12/97 complaining of low back pain for 1 week mad fever for 1 day. He had been seen twice within the 9 days preceding admission for complaints of shoulder and low back pain that were treated symptomatically with nonsteroidal antiinflammatories and analgesics. The patient denied any trauma, abdominal pain, or radicular or urinary symptoms. Physical exam was remarkable for a temperature of 39.5°C orally and mild tenderness to palpation along the paravertebral musculature of the lumbar spine. Laboratory results were remarkable for a bloodureanitrogen level of 53, a creatinine level of 3.1, a white blood cell count of 18.3, and a Westergren erythrocyte sedimentation rate of 113. Urine examination was unremarkable except for 50 mg/dL protein. Plain films of the lumbar spine were essentially unremarkable. Magnetic resonance imaging (MRI) of the lumbar spine showed extensive
epidural contrast enhancement from L1 to L5, suggesting an epidural abscess or phlegmon. The patient was emergently taken to the operating room for laminectomy and drainage and was found intraoperatively to have copious cheesy material (nonpurulent) in the area described by the MRI. After debridement and irrigation, the incision was closed primarily. Laboratory analysis confirmed uric acid tophaceeus material. All cultures were negative. The patient was started on colchicine, and was later discharged home in good condition. This case highlights the importance of a high index of suspicion with regards to the potential for gouty involvement of the spine in patients with gout. In the gout patient with back or neck pain and an otherwise negative workup, computed tomography or MRI should be considered because plain films can be deceptively normal in appearance. The diagnosis is important because gouty spinal involvement has been associated with radicular symptoms, muscular weakness, paraparesis, and quadriparesis. M° Obviously, the potential for significant morbidity exists in these patients. In the patient with or without a history of gout who presents with fever and neck or thoracolumbar back pain, infectious etiologies should also be considered. It is unlikely that patients with a fever and radiological findings suggestive of a spinal abscess would be treated nonoperatively unless comorbid factors made the operation extremely risky. However, if the patient had no other indication for operative decompression and tophaceous gout were confirmed and infection ruled out by less invasive means (eg, by percutaneous sampling), perhaps the operation could be avoided. ROBERTOGINES,MD DEBORAHJ. BATES,MD
Department of Emergency Medicine Medical College of Georgia Augusta, GA
References 1. Fenton P, Young S, Prutis K: Gout of the spine~Two case reports and a review of the literature. J Bone Joint Surg Am 1995;77:767-771 2. Varga J, Giampaolo C, Goldenberg DL: Tophaceous gout of the spine in a patient with no peripheral tophi: Case report and review of the literature. Arthritis Rheum 1985;28:1312-1315 3. Van de Laar MA, Van Soesbergen RM, Matricali B: Tophaceous gout of the cervical spine without peripheral tophi (letter). Arthritis Rheum 1987;30:237-238 4. Jacobs SR, Edeiken J, Rubin B, DeHoratius RJ: Medically reversible quadriparesis in tophaceousgout. Arch Phys Med Rehabil 1985;66:188-190 5. Miller JD, Percy JS: Tophaceous gout in the cervical spine (letter). J Rheumato11984;11:862-865 6. Reynolds AF Jr, Wyler AR, Norris HT: Paraparesis secondary to sodium urate deposits in ligamentum flavum (letter). Arch Neurol 1976;33:795 7. Arnold MH, Brooks PM, Savvas P, Ruff S: Tophaceous gout of the axial skeleton. Aust N Z J Med 1988; 18:865-867 8. Litvak J, Briney W: Extradural spinal depositions of urates producing paraplegia. Case report. J Neurosurg 1973;39:656-658 9. Magid S, Gray GE, Anand A: Spinal cord compression by tophi in a patient with chronic polyarthritis, case report and literature review. Arthritis Rheum 1981 ;24:1431-1434 10. Koskoff YD, Morris LE, Lubic LG: Paraplegia as a complication of gout. JAMA 1953;152:37-38
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 2 • March 1998
acidosis, and may have enabled the avoidance of intubation and mechanical ventilation. Studies are needed to evaluate the effect of heliox therapy on the prognosis of severe acute COPD exacerbation in the emergency department. PATRICKGERBEAUX,MD ALAINBOUSSUGES,MD DOMINIQUETORRO,MD PHILIPPEJEAN, MD
Service d'Accueil et d' Urgences H&pital Conception Marseille, France
References 1. Gluck EH, Onorato DJ, Castriotta R: Helium-oxygen mixtures in intubated patients with status asthmaticus and respiratory acidosis. Chest 1990;98:693-698 2. PolitoA, Fessler H: Heliox in respiratory failure from obstructive lung disease. N Engl J Med 1995;332:192-193 3. Swida DM, Montenegro HD, Goldman MD, et al: Heliumoxygen breathing in severe chronic obstructive pulmonary disease. Chest 1985;87:790-795
TOPHACEOUS LUMBARGOUT MIMICKINGAN EPIDURAL ABSCESS To the Editor:--The diagnosis of gout is rarely difficult in the patient with a known history of gout and an arthritide involving the first metatarsal, tarsometatarsal, or interphalangeal joints. Likewise, the diagnosis is also usually considered in patients with these symptoms and no known history of gout. However, in patients with arthritides not involving these articulations, the diagnosis may be less likely, particularly if the patient has a questionable o1"unknown history of gout. Although included in the differential diagnosis for patients presenting with back pain, spinal involvement with gout is relatively rare. Only 19 such cases exist in the English medical literature to our knowledge. We report the case of a patient who presented to the emergency department with low back pain and who was suspected of having an epidural abscess, and whose symptomatology was subsequently proven to result from lumbar tophaceous gout. Report of a case. A 68-year-old African-American man with a history of congestive heart failure, hypertension, chronic renal insufficiency, gout, and atrial fibrillation presented to our emergency department on 3/12/97 complaining of low back pain for 1 week mad fever for 1 day. He had been seen twice within the 9 days preceding admission for complaints of shoulder and low back pain that were treated symptomatically with nonsteroidal antiinflammatories and analgesics. The patient denied any trauma, abdominal pain, or radicular or urinary symptoms. Physical exam was remarkable for a temperature of 39.5°C orally and mild tenderness to palpation along the paravertebral musculature of the lumbar spine. Laboratory results were remarkable for a bloodureanitrogen level of 53, a creatinine level of 3.1, a white blood cell count of 18.3, and a Westergren erythrocyte sedimentation rate of 113. Urine examination was unremarkable except for 50 mg/dL protein. Plain films of the lumbar spine were essentially unremarkable. Magnetic resonance imaging (MRI) of the lumbar spine showed extensive
epidural contrast enhancement from L1 to L5, suggesting an epidural abscess or phlegmon. The patient was emergently taken to the operating room for laminectomy and drainage and was found intraoperatively to have copious cheesy material (nonpurulent) in the area described by the MRI. After debridement and irrigation, the incision was closed primarily. Laboratory analysis confirmed uric acid tophaceeus material. All cultures were negative. The patient was started on colchicine, and was later discharged home in good condition. This case highlights the importance of a high index of suspicion with regards to the potential for gouty involvement of the spine in patients with gout. In the gout patient with back or neck pain and an otherwise negative workup, computed tomography or MRI should be considered because plain films can be deceptively normal in appearance. The diagnosis is important because gouty spinal involvement has been associated with radicular symptoms, muscular weakness, paraparesis, and quadriparesis. M° Obviously, the potential for significant morbidity exists in these patients. In the patient with or without a history of gout who presents with fever and neck or thoracolumbar back pain, infectious etiologies should also be considered. It is unlikely that patients with a fever and radiological findings suggestive of a spinal abscess would be treated nonoperatively unless comorbid factors made the operation extremely risky. However, if the patient had no other indication for operative decompression and tophaceous gout were confirmed and infection ruled out by less invasive means (eg, by percutaneous sampling), perhaps the operation could be avoided. ROBERTOGINES,MD DEBORAHJ. BATES,MD
Department of Emergency Medicine Medical College of Georgia Augusta, GA
References 1. Fenton P, Young S, Prutis K: Gout of the spine~Two case reports and a review of the literature. J Bone Joint Surg Am 1995;77:767-771 2. Varga J, Giampaolo C, Goldenberg DL: Tophaceous gout of the spine in a patient with no peripheral tophi: Case report and review of the literature. Arthritis Rheum 1985;28:1312-1315 3. Van de Laar MA, Van Soesbergen RM, Matricali B: Tophaceous gout of the cervical spine without peripheral tophi (letter). Arthritis Rheum 1987;30:237-238 4. Jacobs SR, Edeiken J, Rubin B, DeHoratius RJ: Medically reversible quadriparesis in tophaceousgout. Arch Phys Med Rehabil 1985;66:188-190 5. Miller JD, Percy JS: Tophaceous gout in the cervical spine (letter). J Rheumato11984;11:862-865 6. Reynolds AF Jr, Wyler AR, Norris HT: Paraparesis secondary to sodium urate deposits in ligamentum flavum (letter). Arch Neurol 1976;33:795 7. Arnold MH, Brooks PM, Savvas P, Ruff S: Tophaceous gout of the axial skeleton. Aust N Z J Med 1988; 18:865-867 8. Litvak J, Briney W: Extradural spinal depositions of urates producing paraplegia. Case report. J Neurosurg 1973;39:656-658 9. Magid S, Gray GE, Anand A: Spinal cord compression by tophi in a patient with chronic polyarthritis, case report and literature review. Arthritis Rheum 1981 ;24:1431-1434 10. Koskoff YD, Morris LE, Lubic LG: Paraplegia as a complication of gout. JAMA 1953;152:37-38