A 75-year-old man with a history of gout presented with 5 days of fever and diffuse lower back pain. His temperature was 101.5 °F, and he had tenderness over both thoracic and lumbar vertebrae. His neurologic examination was largely normal. Erythrocyte sedimentation rate was 100 mm/h, and serum uric acid 18.6 mg/dL. Subsequent workup, including MRI and biopsy (figure), was consistent with tophaceous gout of the spine. Spinal gout is rarely reported, and can be mistaken for a spinal epidural abscess.1 A recent study suggests the frequency of axial involvement may be as high as 14% in patients with clinical or crystal-proven gout.2
Figure Tophaceous gout of the spine
MRI shows abnormal signal intensity at L4–5 on T1-weighted sequences (A and B inset), with corresponding contrast enhancement (B). Analyses of biopsy were consistent with tophaceous gout. Hematoxylin-eosin stain shows brown aggregates of urate crystals surrounded by an inflammatory reaction (C), and polarizing microscopy reveals typical birefringent crystals (D).
Footnotes
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Disclosure: Dr. Shenoi has received research support from the NIH (5 T32 AI007517) through Yale University, and is currently supported by the Fogarty International Clinical Fellowship (FICRF) (#R24TW007988). Her spouse, Ralph Brooks, was employed by and holds stock option in Merck & Company.
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