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JCR: Journal of Clinical Rheumatology:
doi: 10.1097/RHU.0000000000000105
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Tophaceous Gout Causing Internal Derangement of Knee Joint

Cetin, Pinar MD*; Tuna, Burcin MD; Secil, Mustafa MD; Akar, Servet MD*

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From the *Division of Rheumatology, Department of Internal Medicine, and Departments of †Pathology and ‡Radiodiagnostic, Dokuz Eylul University School of Medicine, Izmir, Turkey.

The authors declare no conflict of interest.

Correspondence: Servet Akar, MD, Division of Rheumatology, Department of Internal Medicine, Dokuz Eylul University School of Medicine, 35340 Inciralti, Izmir, Turkey. E-mail: servet.akar@deu.edu.tr.

Chronic gout is characterized by tophi, which are the collections of monosodium urate crystals and frequently located in subcutaneous and synovial tissues.1 Although the knee is the third most commonly involved joint and intra-articular and periarticular tophi deposition has been previously reported,2 internal derangement due to tophaceous gout is very unusual.3 Here we describe a patient with multiple tophi causing knee joint derangement shown by magnetic resonance imaging.

A 53-year-old man presented with pain and locking sensation in the right knee particularly when he walked down stairs. He has intermittent acute monoarthritis for 10 years. He noticed that arthritis attacks were mostly related with the consumption of alcoholic beverages and shellfish. On physical examination, there was soft tissue swelling in both olecranon bursae (A) compatible with tophi. His right knee was both swollen and deformed, and range of movement was restricted. Anterior drawer test was positive in the right knee. Laboratory analysis showed a serum uric acid level of 10.2 mg/dL. Anteroposterior (B) and lateral (C) radiograph of the right knee showed narrowing of medial joint space, osteophytic new bone formation, and subchondral lucencies. On the posterior side of the joint, multiple rounded opacities were observed, suggesting synovial chondromatosis. Sagittal T1-weighted (E) and T2-weighted (F) magnetic resonance imaging scans demonstrated subchondral cystic changes of the bone and some intermediate signal intensity areas inside the bone that were compatible with intraosseous tophi (dashed arrows) causing the buckling of the posterior cruciate and discontinuation of the anterior cruciate ligament. High-density opacities observed on radiographs were shown to be articular surface tophi (arrows). Analysis of synovial fluid revealed a leukocyte count of 200/µL and needle-shaped crystals in light microscopic examination (D). The patient was diagnosed with chronic tophaceous gout and put on allopurinol and colchicine treatment.

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REFERENCES

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1. Dalbeth N, Clark N, Gregory K, et al. Mechanisms of bone erosion in gout: a quantitative analysis using plain radiography and computed tomography. Ann Rheum Dis. 2009; 68: 1290–1295.

2. Ko KH, Hsu YC, Lee HS, et al. Tophaceous gout of the knee: revisiting MRI patterns in 30 patients. J Clin Rheumatol. 2010; 16: 209–214.

3. Melloni P, Valls R, Yuguero M, et al. An unusual case of tophaceous gout involving the anterior cruciate ligament. Arthroscopy. 2004; 20: e117–e121.

© 2014 by Lippincott Williams & Wilkins, Inc.

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