Abstract: 40-year-old man presented to the clinic with complaints of left
knee pain. His medical history included an 18-year history of gouty
arthritis and on and off treatment for the same. He used to take
nonsteroidal anti-inflammatory drugs for occasional pain in both feet.
He also took allupurinol along with nonsteroidal inflammatory drugs
during acute attacks of joint pain and prophylaxis up to the age of 35
On examination of the left knee, there was no effusion.
Knee movements were clinically normal. Multiple small nodules were seen
on the dorsum of the left hand with a 2-x-3 cm large nodule over the
base of the third metacarpal. They were not warm, not tender, and cystic
to firm in consistency and the underlying extensors tendons were free.
The skin over the nodules was normal and pinchable. There was no
discharging sinus or ulcer noted.
Multiple tophaceous deposits,
grayish discoloration, and hallux valgus deformity were noted on the
great toe on both sides. A large localized swelling was seen in the
retrocalcaneal region of this patient that was cystic in nature, not
warm and tender and free from the tendo calcaneus.
sedimentation rate was 25 mm in the first hour (normal <14). The
patient’s blood parameters revealed hemoglobin 11.2 gms, TLC 7,500/cu
mm. Complete blood counts, C-reactive protein, liver function tests,
creatinine, electrolytes, and thyroid function test and protein
electrophoresis were normal. Tests for antinuclear body, rheumatoid
factor, and HLA-B27 were negative. Serum uric acid was 4.1 mgs (normal
3-7 mgs). Ultrasound KUB was normal. Urine examinations were normal.
of the wrist (Figure 1) showed a circular punched-out lytic lesion
involving scaphoid, capitate, and trapezoid bones. Metacarpals and
phalanges were normal. A radiograph of the feet revealed a classic
‘punched-out’ lytic lesion, marginal erosions, and an associated
overhanging edge at the distal metatarsals.
Straw colored fluid
was aspirated from both the retrocalcaneal region and left wrist dorsal
swelling. Microscopic examination and culture for aerobic, anaerobic,
acid fast, and fungal organisms were negative. Needle-shaped urate
crystals were seen with few RBC’s in between (Figure 2). Pus cells were
He was treated with nonsteroidal anti-inflammatory
drugs, protected weight bearing, and physiotherapy. Four weeks after the
visit, he had improved, with decreased pain and increased movement.
Gouty arthritis. However, calcium pyrophosphate dehydrate deposition
disease (CPPD) and rheumatoid arthritis are the differential diagnoses,
which need to be evaluated both clinico-radiologically and with a
There were multiple small nodules and a large nodule on the dorsum of
left hand at the base of 3rd metacarpal (Figure 1), a localized cystic
granuloma in the retrocalcaneal region is shown, and multiple tophaceous
deposits over the 1st metatarsophalangeal joint and hallux valgus
deformity are seen.
The radiograph (Figure 2) shows a ‘Scalloping
sign’ in capitate and a punched-out lytic lesion involving the scaphoid,
capitate, and trapezoid bones. The radiograph provides (Figure 3)
anteroposterior views of both feet demonstrating punched-out lytic
lesions in the 1st metatarso-phalangeal joints with marginal erosions in
the metatarsal head.
Aspirate of hand and retrocalcaneal region
shows needle shaped urate crystals (Figure 4). The image shows needle
shaped Monosodium urate crystals and flat, plate like colorless uric
acid crystals with numerous RBC’s. No pus cells were seen.
Deposition of gouty tophi in the hand occurs relatively late in the disease and is uncommon with good medical management.1
Radiographic manifestations of gouty arthritis may precede symptoms in
up to 25% of patients and may precede deposition of gouty tophi in up to
42%.2 Gouty arthritis has various modalities of presentations in the hand. This includes acute suppurative flexor tenosynovitis,1,3 carpal tunnel syndrome,1,4 and a localized painful mass in the midpalm,5,6,7 tophi over the dorsal aspect of the interphalangeal and metacarpophalangeal joints.1,2,5
Neglected cases can produce intratendinous infiltration, flexion
contractures, tendon rupture, and skin ulceration in extreme cases.3,6
Gouty tenosynovitis in the hand can be present without tophi or previous involvement of upper extremity.3
Often called “the imitator,” gout may masquerade as septic arthritis,
rheumatoid arthritis or neoplasm, and the diagnosis is often delayed by
weeks or months.
Gout can rarely coexist with rheumatoid arthritis,8 but it is perhaps more frequently misdiagnosed as rheumatoid arthritis because of its proliferative synovitis3 and because 10% to 20% of patients with rheumatoid arthritis have elevated uric acid levels.
early radiological signs of gout are joint effusion and periarticular
edema, caused by the deposition of the nonopaque crystals within the
synovial and cartilaginous tissues.5,6,7 Radiographic
examination eventually reveals a classic ‘punched-out’ lytic lesion with
an associated overhanging edge at the distal metatarsals.6
Multiple marginal erosions and decreased joint space are seen at several
metacarpal-phalangeal joints. These erosions contain sclerotic borders.7
Osteopenia and the loss of joint space are usually not seen until advanced disease stages.6
Additionally, the advanced stage is also characterized by joint
destruction and severe deformities. Proliferative osseous change,
intraosseous cysts, chondrocalcinosis, and olecranon bursitis can
occasionally be seen in the patients with gout.5
diagnosis of gout should not be based on laboratory values alone. Joint
or tenosynovial aspiration, Gram stain, and examination under polarized
light is 85% sensitive for the diagnosis of gout and may be helpful in
differentiating acute gouty tenosynovitis from rheumatoid arthritis or
The asymmetry and lack of joint space
narrowing not seen until advanced stages allow differentiation from
other similar-appearing disorders (eg, psoriasis, osteoarthritis,
infection, and rheumatoid arthritis). CPPD can have symptoms resembling
that of gout and can also occur concomitantly in up to 40% of patients
Our patient who was on long duration of
treatment for gouty arthritis presented to our clinic with nonspecific
knee pain and an incidental radiological evaluation of left hand showed
the involvement of carpal bones. The literature on gout is huge and
refers, not specifically, to every joint. The fact that the carpus has
not been extensively described constituted a base for our presentation.
Histological examination demonstrated urate crystals from the aspirate
of hand and retrocalcaneal region and confirmed the carpal involvement.
Gouty arthritis can also occur in carpal bones. It can occur alone or
along with or without the associated findings. One should always have a
high index of suspicion. Systematic, good clinical examination and
proper radiographs should be carried out. Histology confirms the
diagnosis. Carpal involvement in gouty arthritis should also be kept in
the differential diagnosis in any case of unusual lytic lesions in
Gouty arthritis has various presentations in the
hand. They include acute tenosynovitis, carpal tunnel syndrome, tophi
deposition in the palm, punched-out lytic lesions; and involvement of
the metacarpals. Carpal bones are rarely involved. This case showed the
involvement of carpal bone. One should be careful in interpreting hand
radiographs. A systematic clinical examination along with radiographs
and aspiration cytology confirms the diagnosis.
- Moore JR, Weiland AJ. Gouty tenosynovitis in the hand. J Hand Surg [Am]. 1985;10:291-295.
- Barthelemy CR, Nakayama DA, Carrera GF, et al: Gouty arthritis: A prospective radiographic evaluation of sixty patients. Skeletol Radiol.1984;11:1-8.
- Abrahamsson SO. Gouty tenosynovitis simulating an infection: A case report. Acta Orthop Scand. 1987;58:282-283.
- Janssen T, Rayan GM. Gouty tenosynovitis and compression neuropathy of the median nerve. Clin Orthop Mar. 1987;216:203-206.
- Zayas VM, Calimano MT, Acosta AR, et al. Gout: The radiology and clinical manifestations. Appl Radiol. 2001;30:15-23.
- Uri DS, Dalinka MK. Crystal disease. Radiol Clin North Am.1996;34:359-364.
- Becker MA. Clinical aspects of monosodium urate monohydrate crystal deposition disease (gout). Rheum Dis Clin North Am. 1988;14:377-394.
- Atdjian M, Fernandez-Madrid F. Coexistence of chronic tophaceous gout and rheumatoid arthritis. J Rheumatol. 1981;8:989-992.
- Lagier R, Boivin G, Gerster JC. Carpal tunnel syndrome associated
with mixed calcium pyrophosphate dihydrate and apatite crystal
deposition in tendon synovial sheath. Arthritis Rheum. 1984;27:1190-1195.