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Soloway, Stephen MD, FACP, FACR, CCD
From the Arthritis & Rheumatology Association of SJ.
Correspondence: Stephen Soloway, MD, FACP, FACR, CCD, Arthritis & Rheumatology Association of SJ. E-mail: email@example.com.
This 70-year-old white woman has had tophaceous gout for at least 10 years. She had chronic knee joint pain for many years and had bilateral knee replacements in 1997 because of osteoarthritis. Findings at that surgery were not known. She had done well but recently presented with dramatic left knee pain. She had diabetes, mild renal insufficiency that has gradually gotten worse over the past 10 years, and a low-grade anemia of 11 g/dL. She had hypothyroidism treated with thyroid replacement, bipolar disorder treated with quetiapine fumarate, and hypertension treated with furosemide.
In June 2009, the patient had blood urea nitrogen (BUN) of 55 mg/dL; creatinine, 1.79 mg/dL; and uric acid, 11.2 mg/dL. On a more recent visit, March 2010, the patient had BUN of 65 mg/dL; creatinine, 2.41 mg/dL; and uric acid, 15.3 mg/dL.
Because of the left knee pain and examination consistent with an effusion, a needle aspirate was performed. One hundred milliliters of frank creamy tophus material was obtained (Fig.). This was confirmed under polarized microscopy to contain strongly birefringent crystals with negative elongation.
Of interest, the patient was told at the time of her knee replacement and subsequently by orthopedic surgeons that it is impossible to get gout or arthritis in her replaced knee. The patient is currently asymptomatic with multiple areas of visible tophi.
The patient is allergic to allopurinol because of a severe skin reaction. She was recently prescribed low-dose febuxostat and will be titrated in conjunction with her nephrologists and impending possible dialysis.
© 2011 Lippincott Williams & Wilkins, Inc.
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