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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00727-1
10.1016/j.radcr.2024.07.143
Case Report
Inaugural cervical spinal location of gout: A case report
Coulibaly Abidou Kawélé MD coulibalyabidou@gmail.com
ab⁎
Henchiri Imen MD b
Meunier Marine MD b
Saint-Marcoux Bernadette MD b
a Rheumatology Department, Cocody University Hospital, BP V 13 Abidjan, Côte d’Ivoire
b Robert Ballanger Intercommunal Hospital, Aulnay, Sous-Bois, France
⁎ Corresponding author. coulibalyabidou@gmail.com
24 8 2024
11 2024
24 8 2024
19 11 52385240
4 6 2024
23 7 2024
24 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Gout is a crystalline arthropathy associated with prolonged body overload with uric acid. The most common sites are the distal joints of the lower limbs and the spine is rare. We report a case of gout with an initial cervical location of spondylodiscitis with epiduritis in a 62-year-old patient.

Keywords

Gout
Cervical spine
Spondylodiscitis
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pmcIntroduction

Gout is an inflammatory, metabolic, crystalline arthropathy associated with prolonged uric acid overload [1]. The most common sites are the distal joints of the lower limbs. Some rare or exceptional locations have been described, including the spine [2]. We report a clinical case of an initial spinal location of gout.

Case presentation

The patient was 62 years old, of Romanian origin, an alcoholic and occasional smoker, hypertensive on amlodipine and with a history of ischemic stroke. He suffered from chronic renal failure with a last glomerular filtration rate of 59.5 mL/min and had no known history of gout. He was admitted to the hospital with acute neck pain without any radiation and left ankle pain. The symptoms were inflammatory and had developed suddenly 72 hours before admission. There was no fever, no chills, and no asthenia or weight loss. Moreover, questioning the patient revealed no infectious origin such as cough, otalgia or otorrhea, no odynophagia, no diarrhea, and no dysuria. Physical examination revealed a cervical spinal syndrome with multi-direction spinal stiffness, more precisely, an occiput-to-wall distance of 3 cm and a chin-to-chest distance of 7 cm. The left ankle was slightly warm and swollen, with limited flexion-extension movements. Arthrocentesis of the left ankle yielded 10 mL of cloudy inflammatory fluid. Examination of the other spinal segments, skin and mucous membranes, and cardiovascular and respiratory systems was normal. There were no cervical, axillary or inguinal lymphadenopathy. Biologically, the full blood count was normal, with 9530 white blood cells/mm3. C-reactive protein was high at 232 mg/L. The Uricaemia level was increased at 689 micromol/L. Analysis of the fluid from the left ankle revealed 20,000 white blood cells/mm3, 85% of which were neutrophils, the presence of sodium urate microcrystals, and the absence of germs on direct examination and culture. Blood cultures were negative and cytobacteriologic examination of urine was sterile. An MRI of the cervical spine showed inflammatory oedema of the C4-C5 and C5-C6 vertebral endplates with epidural contrast, suggestive of spondylodiscitis with epiduritis (Fig. 1). X-rays of the left ankle were normal (Fig. 2). Given the involvement of the ankle, hyperuricaemia and the negativity of bacteriological samples, the hypothesis of a gout attack in the cervical spine was mentioned and the patient was put on trial treatment with colchicine. Evolution was marked by a regression of the pain, a reduction of the biological inflammatory marker (C-reactive protein levels reduced to 101 mg/l on day 3 of the treatment) and normalization of the cervical MRI after 1 month of treatment (Fig. 3). We therefore concluded that the patient was suffering from an acute gout attack of the cervical spine and the peripheral joint (left ankle).Fig. 1 MRI of the cervical spine showing C4-C5 and C5-C6 spondylodiscitis with epiduritis.

Fig 1

Fig. 2 X-ray of the left ankle showing thickening of the periarticular soft tissues.

Fig 2

Fig. 3 MRI of the cervical spine showing normalization of images 1 month after the start of colchicine treatment.

Fig 3

Discussion

Rare locations of gout involvement include the spine, the sacroiliac, the sternoclavicular, the manubrium-sternal, the shoulder, the hip, the wrist, the patella, the temporomandibular and the cricoarytenoid joints [2]. In the spine, the lumbar segment is most often involved, followed by the cervical and thoracic segments and the sacroiliac joint [2]. The initial spinal location, as in our clinical case report, is rather rare, with spinal gout occurring in 75% of cases of chronic gout [3]. Acute gout attacks have a caricatured clinical expression with a sudden and intense onset, inflammatory signs that reach their peak in 24 hours associated with general signs such as fever, and their usual clinical course is complete recovery in 7 to 15 days [4]. The same symptoms can occur in the spine as spondylodiscitis, sometimes with epiduritis [5,6], as illustrated by our case. Cases of paravertebral abscesses have been reported [7]. However, spinal gout can present with a variety of symptoms, ranging from simple spinal pain or asymptomatic deposits to spinal cord compression [4]. The main differential diagnosis to be formally ruled out is infectious aetiology, especially in the context of acute febrile inflammatory spinal pain. Spinal computed tomography (CT) scans may show osteolytic lesions of the laminae, vertebral bodies or sometimes the zygapophyseal joints, and investigate the presence of tophus in the form of focal lesions or hyperdense flows associated with calcifications [8]. MRI may show discitis or spondylodiscitis and can be used to assess the impact on the spinal cord. In the presence of a spinal tophus, gadolinium injection frequently shows homogeneous or sometimes only peripheral enhancement, leading to confusion with the appearance of an epidural abscess caused by tuberculosis or common germs, or an intraductal tumor process [5]. The definitive diagnosis is anatomopathological using disco-vertebral or soft tissue biopsy, which allows intra-lesion visualization of sodium urate crystals [2]. Treatment of spinal gout is broadly the same as for peripheral joint disease [4]. It is based on drugs such as nonsteroidal anti-inflammatory drugs, corticosteroids, colchicine or interleukin-1 inhibitors, and surgery in cases of neurological compression or spinal instability [4,9].

Conclusion

Gout rarely involves the spine. They may present as acute inflammatory neck pain and should be discussed as a differential diagnosis of infectious aetiology, in particular pyogenic spondylodiscitis.

Patient consent

The authors have obtained written informed consent for publication from the patient.

Competing Interests: The authors declare no conflict of interest.
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