Gouty sacroiliitis: A case report of often-overlooked cause of inflammatory back pain

Written By : Dr Supreeth D R |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2023-02-06T20:00:43+05:30 | Updated On 6 Feb 2023 8:00 PM IST

Gout is a chronic disease caused by monosodium urate crystal deposition, typically affecting the big toe, midfoot, and ankle. As it rarely involves the sacroiliac joints, it could be easily misdiagnosed as spondylarthritis.

Qi-Hong Guo et al reported the case of a patient with a long history of gout with recurrent low back pain. Computed tomography of the sacroiliac joint suggested sacroiliac arthritis, puncture biopsy indicated gout granuloma, and polarized light microscopy confirmed monosodium urate crystal deposits.

A 34-year-old man with recurrent pain and swelling of the large joints of the feet for the last 5 years, diagnosed with gout and erratically taking febuxostat tablets presented with recurrent attacks of low back pain for 1 year, especially at night and aggravated by activity, limited movement of lower limbs, and difficulty walking during episodes that were not completely relieved by nonsteroidal anti-inflammatory drugs. He denied any history of ophthalmia, inflammatory bowel disease, or psoriasis rash manifestation. He had a family history of gout but not of ankylosing spondylitis. The authors found no visible tophi on him, and the lumbar and thoracic spine mobility was normal.

Laboratory investigation showed elevated serum creatinine (126.2 μmol/L; normal up to 104 μmol/L), uric acid (708.8 μmol/L), C-reactive protein (13.5 mg/L; normal up to 10 mg/L), and ESR (3 mm/h, normal up to 20 mm/h), and the HLA-B27, antinuclear antibodies, rheumatoid factor, and anti-cyclic citrullinated peptide antibodies were all negative. A computed tomography (CT) scan found “edge of uvula”-like change at the left sacroiliac joint. Dual-energy CT (DECT) revealed urate deposits at the sacroiliac joints. Ultrasound identified MSU crystal deposits at the right big toe.

A CT-guided percutaneous needle aspiration of the sacroiliac joint was performed, and pathological investigation showed hyaline fibrous and gout granuloma, with strong negative bi-refringent needle-shaped crystals on polarized light microscopy, confirming the presence of MSU. The clinical symptoms were relieved after colchicine and febuxostat treatment, with uric acid levels at 403 μmol/L and C-reactive protein at 0.34 mg/L.

The authors commented that “Gout is the most common inflammatory arthritis affecting adults, which can co-exist with other forms of arthritis. Gouty sacroiliitis is an often-overlooked cause of inflammatory back pain. This case description aims to raise awareness of the disease and reduce misdiagnosis and underdiagnosis.”

MBBS, Dip. Ortho, DNB ortho, MNAMS

Dr Supreeth D R (MBBS, Dip. Ortho, DNB ortho, MNAMS) is a practicing orthopedician with interest in medical research and publishing articles. He completed MBBS from mysore medical college, dip ortho from Trivandrum medical college and sec. DNB from Manipal Hospital, Bengaluru. He has expirence of 7years in the field of orthopedics. He has presented scientific papers & posters in various state, national and international conferences. His interest in writing articles lead the way to join medical dialogues. He can be contacted at editorial@medicaldialogues.in.

Dr. Kamal Kant Kohli

Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751