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CONCOMITANT GOUT and RHEUMATOID ARTHRITIS - a CASE Presented with Multiple Nodular Swellings on REPORT Feet, Hands, Wrists and Elbows

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349 350 INDIAN JOURNAL OF MEDICAL SCIENCES CASE REPORT consulted various practitioners and took allopathic and indigenous medications but to no relief. Two months prior to admission he CONCOMITANT GOUT AND RHEUMATOID ARTHRITIS - A CASE presented with multiple nodular swellings on REPORT feet, hands, wrists and elbows. Patient’s past medical history is significant for hypertension, POOJA KHOSLA*, ATUL GOGIA**, P. K. AGARWAL***, AMIT PAHUJA**, SUNIL JAIN***, K. K. SAXENA# diabetes mellitus, chronic ethanolism and renal stones for which he underwent left nephrectomy about 25 years ago. Family Abstract history is non-contributory. Figure 1: Multiple nodules present on metatarsal joints of both feet (Gouty Tophi) We report a case of definite rheumatoid arthritis and co-existing gout. Although gout On examination multiple nodules were present and rheumatoid arthritis are relatively common entities individually, the co-existence on metatarsal joints of both feet, Achilles of these two conditions is rare. tendon bilaterally, left prepatellar bursa, bilateral metacarpophalangeal joint, right KEY WORDS: Gout, Rheumatoid Arthritis olecranon process. There was swelling and tenderness of PIP and MCP joints of both feet. (Figure 1) Laboratory data revealed INTRODUCTION metatarsophalangeal joint. He had hemoglobin - 8.9gm/dl, ESR 124 mm at the asymmetrical joint pains and swelling at end of first hour, leucocyte count 7400/cmm Gout and rheumatoid arthritis rarely co-exist in irregular intervals with exacerbations and with normal differential count. Random blood the same patient. As separate disease entities remissions. The symptoms subsided in sugar was 139 mg/dl, Creatinine- 1.6 mg/dl; they are relatively common. Rheumatoid between but there was no period when patient serum uric acid level was 10.9 mg/dl. His 24 Figure 2: X-ray both hands showed subarticular arthritis affects 2-3% of the population1 with a was completely pain free. He did not have hour urinary uric acid excretion was 446 mg/ erosions at distal end of radius, ulna, Scaphoid, female to male ratio of 3:1, while gout affects associated warmth and erythema although dl. Serum calcium, phosphorus, LFT, radial aspect of 2nd and 3rd proximal interphalangeal joint bilateral and left triquetral with 0.25% of the population, with 90% of the cases swelling and tenderness were present. Three electrolytes and lipid profile were normal. associated soft tissue swelling occurring in males.1 It has been reported that years after onset of joint pains, patient started Serum iron was 7 mg/dl, TIBC 244 mg/dl. Stool there is a strong negative correlation between having pain in small joints of hands, knees, for occult blood was negative. Rheumatoid femoral and patello-femoral joint space with rheumatoid arthritis and gout.2 ankles, shoulders and elbows, with early factor was 2560 iu/ml (by latex agglutination subarticular lytic area, sclerosis and soft tissue morning stiffness lasting for more than four method) and CRP was 96 mg/dl. X-rays of both swelling bilaterally right more than left. These CASE HISTORY hours. Joint pains were incapacitating and he feet showed multiple lytic areas in 2nd and 3rd findings were suggestive of gout lus had to quit his job. Initially pain was localized metatarsal and tarsal bones. X-rays of both rheumatoid arthritis. X-ray pelvis showed A 55-year-old ex-army man was admitted with to the ankles and left 1st metatarsophalangeal elbows showed soft tissue swelling at bilateral sacroiliitis. Sonography of the a 10-year history of pain in the ankle joints joint but gradually went on to involve the rest olecranon process, right more than left. X-rays abdomen revealed mild hepatomegaly with followed by involvement of left 1st of the joints over the next 7 years or so. He of both hands showed subarticular erosions at grade I fatty changes with right kidney 12.4x4.6 distal end of radius, ulna, scaphoid, radial cm in size. Thick chalky white fluid was aspect of 2nd and 3rd proximal interphalangeal aspirated from the nodular swelling at the right Correspondence: *Registrar, ***Consultant, **Resident-Department of Dr. Atul Gogia, Resident, Department of Medicine, J-6/27 joints bilaterally and left triquetrum with metatarsophalangeal joint. It was alkaline with # Medicine, Consultant, Department of Radiology, Rajouri Garden, New Delhi - 110 027. India. associated soft tissue swelling (Figure 2). X- numerous polymorphs, WBC 25000 cells/cmm, Sir Ganga Ram Hospital, Rajinder Nagar, E-mail: [email protected] New Delhi - 110060, India. ray of both knees revealed reduced tibio- 90% polymorphs and 10% lymphocytes with Indian J Med Sci Vol. 58 No. 8, August 2004 Indian J Med Sci Vol. 58 No. 8, August 2004 CONCOMITANT GOUT AND RHEUMATOID ARTHRITIS 351352 INDIAN JOURNAL OF MEDICAL SCIENCES monosodium urate crystals with birefringence. and the high titer of RF (1:2560) support the started. Patient underwent arthroscopy of the right diagnosis of RA beyond doubt. Unusual feature knee and synovial biopsy was taken. observed in our patient was bilateral sacroilitis. REFERENCES Arthroscopic finding revealed synovial This is an uncommon finding, seen in 1. Spector AK, Christman RA. Arthritis. Journal of hypertrophy with gouty crystals embedded and rheumatoid arthritis.7 There is no clear data on the America Podiatric Medical Association spread everywhere in the joint. Synovial biopsy Sacroilitis in gout but cases showing sacroilitis 1989;79:552-8. was compatible with gouty tophi in synovium in gout have been reported (Reference: Talbott 2. Atdjian, Fernandez-Madrid F. Coexistence of along with rheumatoid nodule like structure JH, Altman RD, Yu TF. Gouty arthritis chronic Tophaceous Gout and Rheumatoid (Figure 3). Diagnosis of chronic tophaceous masquerading as Rheumatoid arthritis. Arthritis. J Rheumatol 1981;8:989-92. gout with rheumatoid arthritis was made and Seminars in Arthritis and Rheumatism 1978; 3. Martinez-Cordero E, Bessudo-Babani A, Perez the patient was started on colchicine, Figure 3: Synovial biopsy showing gouty crystals along 8(2): 100-101. SCT, Guillermo-Grajales E. Concomitant Gout with rheumatoid nodule like structure. allopurinol and methotrexate. and Rheumatoid Arthritis. J Rheumatol We agree with Atdijian and Fernandez and 1988;15:1307-11. DISCUSSION gradually progressive.) or vice versa. In all Rizzoli et al2,6 that diagnosis of this coexistence 4. Wallace DJ, Klinenberg JR, Morhaim D, cases in which gout and RA were associated can be made with certainty by finding the Berlanstein B, Biren PC, Callis G. Coexistent The co-existence of gout and RA may be no difficulty was encountered in establishing histological evidence of rheumatoid nodules Gout and Rheumatoid Arthritis. Arthritis and 2 supported by both clinical and laboratory the diagnosis of gout. Papers in the literature and monosodium urate crystal deposition. Rheumatism. 1979;22:81-6. 5. Talbott JH, Altman RD, Yu TF: Gout arthritis criteria.3 clearly document the presence of gout but rely Synovial biopsy from right knee in our patient masquerading as rheumatoid arthritis or vice on the presence of morning stiffness, had changes of gout and rheumatoid arthritis. versa. Semin Arthritis Rheum 1978;8:77-114. Our patient had recurrent gouty attacks symmetrical synovitis and positive RF with low The fixation of biopsy materials in alcohol is superimposed by rheumatoid arthritis. He had or high titer for the diagnosis of RA.2 Morning 6. Rizzoli AJ, Trujeque L, Bankhurst AD. The important since granulomas with histologic coexistence of gout and rheumatoid arthritis: high serum uric acid; monosodium urate stiffness and fusiform swelling of PIP and MCP features resembling rheumatoid nodules or Case reports and a Review of Literature. Journal deposit in subcutaneous nodules, high titer of joints, though suggestive of RA, are misleading rheumatoid synovitis may show crystals of of Rheumatology 1980;7:316-24. RF, radiographic changes of gout and erosive since these findings can occur in polyarticular MSU when examined under contrast polarizing 7. De Carvalho A, Graudal H. Sacroiliac joint tophaceous gout. It has been reported that RA and histological evidence of a rheumatoid light microscope.2 After a confirmed diagnosis, involvement in classical or definite rheumatoid arthritis. These manifestations have been chronic synovitis in gout may also simulate RA treatment with Disease modifying drugs along arthritis. Acta Radiol Diagn (Stockh) 2 proposed as the criteria for the coexistence of when studied by means of arthrography. The with hypouricemic therapy can be safely 1980;21:417-23. both diseases.4 A literature review revealed 17 presence of lymphocytic infiltration with patients with concomitant gout and RA.3,5 The germinal centers and the absence of crystals difficulty of reaching a diagnosis of coexistence in the chronic synovitis support the diagnosis of both diseases may be due to the fact that it of RA.2 and a high incidence of positive test takes time to establish definite evidence of for RF has been reported in gout without gout clinically as chronic tophaceous gout clinical evidence of RA. Kozin and McCarty1 mimics rheumatoid arthritis, so a clinician does found 30% of patient with chronic topahceous not suspect the condition. RA or their gout and 10% of patients with acute gout to concurrence. Many features of gout during the have rheumatoid factor present in low titers evolution of the disease may mimic RA (We (<1:320). Other researchers also found positive would like to tell that we are not talking about titers of RF, but in a smaller percentage of acute gout but it is chronic tophaceous gout patients.6 In our case, the pathological and it has a similar course i.e. insidious and changes present, in the synovial membrane Indian J Med Sci Vol. 58 No. 8, August 2004 Indian J Med Sci Vol. 58 No. 8, August 2004.
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