Tophaceous gout in the elderly: a clinical case review

New-Onset Rapidly Progressive Polyarticular Tophaceous Gout After Cerebrovascular Accident

ABSTRACT

We present a novel case of new-onset, polyarticular tophaceous gout, which developed on the patient's hemiparetic side several days after she was diagnosed with a middle cerebral artery stroke. This is the first case of an acute gout flare in a patient without history of gout. She was successfully treated with anakinra.

Simple metabolic markers associated with tophaceous gout

INTRODUCTION

The relationship between tophaceous gout and metabolic markers is not well understood. The aim of this study was to compare the correlations between different metabolic markers and tophi and evaluate their potential predictive values for tophus.

METHOD

We analysed the data of gout patients in Beijing Jishuitan Hospital from 2013 to 2020. Ten laboratory indicators (UA, eGFR, underexcretion, GLU, TRIG, HDL-C, ALT, TBIL, γ-GT and UPH) were included to evaluate the relationship between tophaceous gout and metabolic markers.

RESULTS

Tophi was present in 14.7% (119/808) of gout patients. UA, eGFR, ALT and γ-GT were independently related to the development of tophi; UA and γ-GT were positively correlated. The γ-GT/ALT ratio and UA/eGFR ratio showed a positive correlation with tophi, with (rho, P) of (0.305, < 0.001) and (0.195, < 0.001), respectively. The γ-GT/ALT ratio showed the best classificatory performance (AUC = 0.749, P < 0.001) for tophi among the four positive correlation indicators. With increasing integer γ-GT/ALT ratio, the incidence of tophi (4.9%, 9.7%, 22.3% and 38.4%, P < 0.001), chronic kidney disease (2.5%, 5.2%, 12.3% and 19.2%, P < 0.001) and hyperuricemia over 10 years (6.6%, 10.7%, 18.5% and 26.4%, P < 0.001) showed a progressive increase. The γ-GT/ALT ratio was positively correlated with the number of tophi and duration of hyperuricemia, negatively correlated with eGFR.

CONCLUSIONS

UA, eGFR, γ-GT and ALT were independently associated with tophi. The γ-GT/ALT ratio may be used as a predictor or monitor of tophi.

Geriatric Rheumatology: The Need for a Separate Subspecialty in the Near Future

Rheumatology is a broad specialty in itself, and it involves caring for patients of all age groups. Patients of different age groups have different characteristics and a one-size-fits-all approach is not feasible in catering to their diverse medical needs. The presentation and the manifestations of diseases vary in different age groups. We have pediatric rheumatology as a separate subspecialty where pediatric patients with rheumatological diseases are provided specific care best suited to their needs. However, for older patients, such a separate subspecialty is not widely available in medical practice. Geriatric rheumatology or gerontorheumatology is a branch of rheumatology dealing with older patients with rheumatological diseases. It is high time to consider establishing geriatric rheumatology as a separate subspecialty to provide better care for older patients.

Conventional Radiology in Crystal Arthritis: Gout, Calcium Pyrophosphate Deposition, and Basic Calcium Phosphate Crystals

This article reviews the main radiographic features of crystal deposition diseases. Gout is linked to monosodium urate crystals. Classic radiographic features include subcutaneous tophi, large and well-circumscribed paraarticular bone erosions, and exuberant bone hyperostosis. Calcium pyrophosphate deposition (CPPD) can involve numerous structures, such as hyaline cartilages, fibrocartilages, or tendons. CPPD arthropathy involves joints usually spared by osteoarthritis. Basic calcium phosphate deposits are periarticular or intraarticular. Periarticular calcifications are amorphous, dense, and round or oval with well-limited borders, and most are asymptomatic. When resorbing, they become cloudy and less dense with an ill-defined shape and can migrate into adjacent structures.

Multiple Asymptomatic Juxta-Articular Nodules Mimicking Tuberous-Xanthoma-A Unusual Presentation of Tophaceous Gout

Asymptomatic, juxta-articular nodules are an uncommon morphology, which is usually diagnosed as xanthomas, calcinosis cutis or rheumatoid nodules. This study was represented as a case of gout, which is a disorder of purine metabolism resulting in elevation of serum uric acid and deposition of monosodium urate crystals within and around joints and manifests clinically as inflammatory arthritis. Urate crystal deposits have also been found in tendons, ligaments, viscera, and the skin, with the term “tophi” being used for the non-articular deposits. In the chronic stage, the lesion can be asymptomatic lesions and is often misdiagnosed.

Hyperuricemia protects against low bone mineral density, osteoporosis and fractures: a systematic review and meta-analysis

BACKGROUND

Serum uric acid (SUA) accounts for about 50% of extracellular antioxidant activity, suggesting that hyperuricemia may have a protective role in diseases characterized by high levels of oxidative stress, such as osteoporosis. We aimed to meta-analyse data regarding bone mineral density (BMD), osteoporosis and fractures in people with higher SUA vs. lower SUA concentrations.

MATERIALS AND METHODS

Two investigators conducted a literature search using PubMed and Scopus, without language restrictions. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were used for BMD; risk ratios (RRs) and adjusted odds ratios (ORs) for cross-sectional data. Most possible adjusted hazard ratios (HRs) were used to assess the association between baseline SUA and incident fractures.

RESULTS

Of 1405 initial hits, 19 studies were eligible including a total of 55 859 participants. Subjects with higher SUA levels had significantly higher BMD values for the spine (six studies; SMD = 0·29; 95% CI: 0·22-0·35; I² = 47%), total hip (seven studies; SMD = 0·29; 95% CI: 0·24-0·34; I² = 33%) and femoral neck (six studies; SMD = 0·25; 95% CI: 0·16-0·34; I² = 71%). Simple correlation analyses substantially confirmed these findings. An increase of one standard deviation in SUA levels reduced the number of new fractures at follow-up (three studies; HR = 0·83; 95% CI: 0·74-0·92; I² = 0%). No significant differences between men and women emerged, although data about women were limited.

CONCLUSIONS

Hyperuricemia was found independently associated with BMD and fractures, supporting a protective role for uric acid in bone metabolism disorders.

Oxidative stress and antioxidant levels in patients with anorexia nervosa: A systematic review and exploratory meta-analysis

OBJECTIVE

To systematically review and meta-analyze oxidative stress and antioxidant markers in anorexia nervosa (AN).

METHODS

Electronic PubMed search from database inception until 12/31/2013. Out of 1062 hits, 29 studies comparing oxidative stress/antioxidant markers between patients with AN and healthy controls (HCs) with a total of 1,729 participants (AN = 895, HCs = 834) were eligible. Data about oxidative stress and antioxidant markers, independent of their source, were extracted. We calculated random effects standardized mean differences (SMDs) as effect size measures for outcomes reported in ≥5 studies; others were summarized descriptively.

RESULTS

Compared to HCs, AN patients showed significantly higher apolipoprotein B (ApoB) levels (studies = 7; n = 551; SMD = 0.75; p = .0003, I(2)  = 74%), with higher age being associated with higher ApoB (Coefficient: 0.61 ± 0.15, p < .0001), whereas BMI (p = .15) and measurement method (p = .70) did not moderate the results. Serum albumin levels were similar between AN and HCs (studies = 13; n = 509; SMD =-0.19; 95%CI: -0.62 to 0.24; p = .38; I(2)  = 81%), with neither age (p = .84) nor BMI (p = .52) being significant moderators. Lower superoxide dismutase levels were reported in 2 studies, while findings for vitamin A and its metabolites were inconclusive. In single studies, patients with AN had significantly higher catalase and nitric oxide (NO) parameter levels (platelet NO, exhaled NO and nitrites), such as lower glutathione and free cysteine levels, compared to HCs.

DISCUSSION

AN appears to be associated with some markers of increased oxidative stress. Additional research is needed to discern whether oxidative stress is a potential cause or effect of AN, and whether treatments improving oxidative stress could be useful in AN.

Serum uric acid and incident osteoporotic fractures in old people: The PRO.V.A study

PURPOSE

Although high serum uric acid (SUA) levels are associated with negative outcomes in older people, recent studies reported that hyperuricemia could help protect against the onset of bone fractures. We consequently examined whether baseline SUA levels were associated with risk of incident osteoporotic fractures in a representative group of elderly people with no fractures or other bone-modifying conditions or drugs at the baseline.

METHODS

Among 3099 people aged ≥ 65 years initially involved in the PRO.V.A. study, 1586 participants with no prior diagnosis of osteoporotic fractures, and no conditions or medication affecting bone metabolism at the baseline were followed up for 4.4 ± 1.2 years. Baseline SUA levels were classified in gender-specific quintiles. Incident osteoporotic fractures were considered as any new fractures occurring at the usual sites of osteoporotic fractures.

RESULTS

At the baseline, participants with higher SUA levels had significantly less osteoporosis and lower serum beta cross-laps levels, but higher serum parathormone concentrations irrespective of gender. Over a 4.4-year follow-up, 185 subjects were diagnosed with a new osteoporotic fracture, giving rise to an incidence of 25 events per 1,000 person-years. Cox's regression analysis, adjusted for potential baseline and follow-up confounders, revealed no relationship between high SUA levels and incident fractures during the follow-up in the sample as a whole (p for trend=0.46) or by gender (p for trend=0.14 in males and 0.64 in females).

CONCLUSIONS

Baseline SUA concentrations were not associated with the onset of new osteoporotic fractures over a 4.4-year follow-up in our sample of community-dwelling older men and women.

Multiple Cutaneous Creamy Papules and Nodules: A Case of Miliarial Gout

BACKGROUND

Tophaceous gout is the nonarticular deposition of monosodium urate resulting from a disorder in purine metabolism that causes an elevation of serum uric acid. Cutaneous variants of tophaceous gout include papular, nodular, ulcerative, and pustular forms.

OBJECTIVE

We present a case of a 67-year-old man who presented with multiple cutaneous creamy white papules and nodules. A biopsy was taken, and a diagnosis of cutaneous tophaceous gout was made. The treatment and pathophysiology are discussed.

CONCLUSION

Miliarial gout is a rare form of cutaneous tophaceous gout that is treated using xanthine oxidase inhibitors such as allopurinol and febuxostat or uricosurics such as probenecid.

Gadolinium-enhanced MRI features of acute gouty arthritis on top of chronic gouty involvement in different joints

The aims of the current study are to describe gadolinium-enhanced MRI features of an acute flare of established gouty arthritis in different joints and to examine a possible association between serum uric acid and MRI signs indicative of ongoing inflammation and/or structural joint damage as well as association with disease characteristics and laboratory findings. Twenty-seven male patients with established chronic gout agreed to participate, mean age 47.6 years, and mean disease duration in months 43.2 (±31.8). For all patients, detailed demographic, disease characteristics, and laboratory findings were obtained and correlated with MRI findings. In 27 patients with established gout, a total of 50 MRI studies were performed of the following joints: feet joints (n = 23), ankles (n = 18), knees (n = 5), and hand and wrist joints (n = 4). MRI revealed capsular thickening in 19 patients, bone marrow edema (BME) in 15, soft tissue edema (STE) in 20, joint effusion in 21, bone erosions in 17, cartilaginous erosions in 4, and tenosynovitis in 9 cases. In 17 cases, tophaceous lesions were found. Post contrast MRI showed synovial thickening in seven cases. Positive correlations were observed between serum uric acid levels and the following MRI findings: capsular thickening (r = 0.552, p = 0.003), BME (r = 0.668, p ≤ 0.0001), STE (r = 0.559, p = 0.002), and tenosynovitis (r = 0.513, p = 0.006). Using MRI in chronic gout, important features can be detected like BME, minute cartilaginous erosions, and hypertrophic synovial inflammation in post contrast MR images. Serum uric acid (SUA) was positively correlated with capsular thickening, BME, STE, and tenosynovitis.

[An elderly man presenting polyarthritis diagnosed as chronic tophaceous gout]

An 85-year-old man was admitted to our hospital for swollen and painful bilateral lower legs and a high fever. He was initially diagnosed with acute cellulitis and treated with antibiotics. Several days after the improvement of his swollen legs, he complained of both shoulder and arm pain. The laboratory data at this time were as follow: C-reactive protein 10.7 mg/dL, uric acid 8.7 mg/dL, and creatinine 1.07 mg/dL. Both rheumatoid factor and anti-CCP antibody were negative. Whole-body gallium scintigraphy showed a high pathological accumulation in both the shoulders and left wrist. As polymyalgia rheumatica was suspected, oral prednisolone (PSL) of 10 mg/day was started. The patient's shoulder pain improved and he was discharged. However, he was hospitalized twice in the next month because of left shoulder, left knee, right arm, and right wrist pain. During the third hospitalization, we found a subcutaneous nodule on right toe. Aspiration material from the nodule was a white paste, showing acicular crystals under the microscope. According to these findings, the nodule was diagnosed as a tophaceous nodule, and recurrent episodes of polyarthritis were diagnosed as chronic tophaceous gout. Low-dose PSL was continued and febuxostat was added. This patient had multiple risk factors for chronic tophaceous gout: obesity, a habit of drinking, diabetes mellitus, hyperlipidemia, congestive heart failure, and interruption of allopurinol treatment. We herein discuss the clinical course of the patient, the interruption of allopurinol treatment and polypharmacy in elderly patients.

Chronic gout in the elderly

Gout is the most common cause of inflammatory arthritis in men over 40 years old; it is a debilitating disease and, if untreated, can result in a chronic progressive disease, including tophaceous gout. In the elderly it represents a special issue, with notable clinical and therapeutic differences from the classical form with a systemic involvement. The burden of the disease increases particularly in the very old people, in whom arthritis, impaired gait and eyesight problems may enhance the related disability. Chronic gout moreover could aggravate heart and kidney disease and increase overall mortality and organ-related damage. Early diagnosis and appropriate treatment are important goals for the clinician that should to rely on the cooperation of specialists working together through the methodology of comprehensive geriatric assessment. The aim of the present review was to analyze chronic gout in old people in terms of epidemiology, pathophysiology, risk factors, clinical approach, and current treatment.