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JCR: Journal of Clinical Rheumatology:
doi: 10.1097/RHU.0b013e31827cdd8f
Concise Reports

Unusual Soft Tissue Mass of the Left Lower Leg

Hsu, Shun-Neng MD*; Hsu, Yi-Chih MD; Lin, Cheng-Hui MD; Chiu, Sheng-Kang MD*

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From the *Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, †Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei; and ‡Division of Rheumatology, Immunology and Allergy, Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, Republic of China.

The authors declare no conflict of interest.

Correspondence: Sheng-Kang Chiu, MD, Division of Infection and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, 325, Sec 2, Cheng-Kung Rd, Neihu 114, Taipei, Taiwan, Republic of China. E-mail: skchiu@ndmctsgh.edu.tw.

A 56-year-old man presented with a 3-day history of fever and painful disability in walking and standing. He had symptoms of painful swelling of the left lower leg off and on for 1 year. He denied any history of trauma. He had a 20-year history of gouty arthritis without adequate low-purine diet and medication control. He had consumed 2 to 3 pints of whisky (with the alcohol content of about 40%) per day for more than 20 years. Upon clinical examination, tophi were evident over his right wrist and ankle, and a palpable, painful, hard mass over the left lower leg was noted. The laboratory values were as follows: white blood cells 18,570/µL, neutrophils 81%, C-reactive protein 39.55 mg/dL, creatinine 0.9 mg/dL, and uric acid 10 mg/dL. A plain radiograph of the left lower leg (A) showed a lobulated soft tissue mass (>20 cm in diameter). Musculoskeletal ultrasonography in the transverse axis views (C) showed an inhomogeneous hypoechoic to hyperechoic lobulated cystic mass (arrows), which destroyed the normal feather-like pattern of the left calf muscle (black asterisks show the gastrocnemius muscle, and white asterisks show the tibia). We performed ultrasound-guided drainage of the lobulated cystic lesions (B), and a total of about 350 mL of white chalky substance (D) was aspirated. The aspirated fluids had fewer than 1000 white blood cells/µL, and routine cultures were negative for bacteria and tuberculosis. Compensated polarized light microscopy revealed monosodium urate crystals, which are pathognomonic for gouty tophi.

With inadequately treated hyperuricemia, transition to chronic tophaceous gout often involves polyarticular attacks, and crystal deposition (tophi) in soft tissues or joints.1–2 Acute gout inflammation of a cystic tophaceous lesion of a leg muscle (muscular gout) is rare and remains a diagnostic and management challenge.3 Appropriate therapeutic options for the muscular gout require long-term treatment with urate-lowering therapy to reverse the chronic urate crystal deposition and to prevent recurrent flares. In this case, ultrasound-guided aspiration not only significantly diminished the swollen mass, but also reduced acute symptomatic discomfort rapidly. In an era when ultrasound imaging is increasingly used to diagnose muscle and skeletal disease, physicians should be aware of this atypical presentation.

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REFERENCES

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1. Smith EU, Díaz-Torné C, Perez-Ruiz F, et al.. Epidemiology of gout: an update. Best Pract Res Clin Rheumatol. 2010; 24: 811–827.

2. Neogi T. Clinical practice. Gout N Engl J Med. 2011; 364: 443–452.

3. Huang GS, Chang DM, Chang WC, et al.. Acute gouty inflammation of a cystic tophaceous lesion of a leg muscle associated with “urate milk”. J Rheumatol. 2005; 32: 2443–2444.

© 2013 Lippincott Williams & Wilkins, Inc.

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