1/7. Tophaceous gout of the spine mimicking epidural infection: case report and review of the literature.OBJECTIVE AND IMPORTANCE: Tophaceous gout uncommonly affects the axial skeleton. The clinical presentations of gout of the spine range from back pain to quadriplegia. gout that presents as back pain and fever may be difficult to distinguish from spinal infection. We present a case of a patient with tophaceous gout of the lumbar spine who was initially diagnosed with and treated for an epidural infection. The clinical and diagnostic features of tophaceous gout of the spine are reviewed. CLINICAL PRESENTATION: A 70-year-old man presented with a 2-day history of fever and back pain. A physical examination revealed that he had flank tenderness and evidence of polyarthritis affecting the elbows, knees, and right first metatarsophalangeal joint. A magnetic resonance imaging scan of the patient's lumbar spine showed an extensive area of abnormal gadolinium enhancement of the paramedian posterior soft tissues from L3 to S1 with an area of focal enhancement extending into the right L4-L5 facet joint. INTERVENTION: A laminectomy was performed at L4-L5, and a chalky white material in the facet joint was found eroding into the adjacent pars intra-articularis. light and polarizing microscopy confirmed the presence of gouty tophus. No evidence of infection was found. CONCLUSION: Gouty arthritis of the spine is rare. Thirty-seven previous cases have been reported. When the clinical presentation includes acute back pain and fever, differentiation of spinal gout from spinal infection may be difficult. The clinical suspicion of spinal gout may lead to the correct diagnosis by a less invasive approach than exploration and laminectomy.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/7. hypoxanthine-guanine phosphoribosyltransferase. Characterization of a mutant in a patient with gout.The mutation in a young gouty male with a partial deficiency of hypoxanthine-guanine phosphoribosyltransferase has been evaluated. The serum uric acid was 11.8 mg/100 ml, and the urinary uric acid excretion was 1,279 mg/24 h. Erythrocyte hypoxanthine-guanine phosphoribosyltransferase was 34.2 nmol/h/mg, adenine phosphoribosyltransferase was 36.5 nmol/h/mg and phosphoribosylpyrophosphate was 2.6 muM. hypoxanthine-guanine phosphoribosyltransferase from peripheral leukocytes and cultured diploid skin fibroblasts was within the normal range, but enzyme activity in rectal mucosa was below the normal range. Initial velocity studies of the normal enzyme and the mutant enzyme from erythrocytes with the substrates hypoxanthine, guanine, or phosphoribosylpyrophosphate showed that the Michaelis constants were similar. Product inhibition studies distinguished the mutant enzyme from the normal enzyme. Hyperbolic kinetics with increasing phosphoribosylpyrophosphate were converted to sigmoid kinetics by 0.2 mM GMP with the mutant enzyme but not with the normal enzyme. The mutant erythrocyte hypoxanthine-guanine phosphoribosyltransferase was inactivated normally at 80 degrees C and had a normal half-life in the peripheral circulation. The mol wt of 48,000 was similar to the normal enzyme mol wt of 47,000. With isoelectric focusing, the mutant erythrocyte enzyme had two major peaks with isoelectric pH's of 5.50 and 5.70, in contrast to the isoelectric pH's of 5.76, 5.82, and 6.02 of the normal isozymes. isoelectric focusing of leukocyte extracts from the patient revealed the presence of the mutant enzyme. Cultured diploid fibroblasts from the propositus appeared to function normally, as shown by the inability to grow in 50-100 muM azaguanine and by the normal incorporation of [14C]hypoxanthine into nucleic acid. In contrast, erythrocytes from the patient displayed abnormal properties, including the increased synthesis of phosphoribosylphyrophosphate and elevated functional activity of orotate phosphoribosyltransferase and orotidylic decarboxylase. These unique kinetic, physical, and functional properties provide support for heterogeneous structural gene mutations in partial deficiencies of hypoxanthine-guanine phosphoribosyltransferase.- - - - - - - - - - ranking = 0.085591158588473keywords = physical (Clic here for more details about this article) |
3/7. Limited knee joint range of motion due to invisible gouty tophi.OBJECTIVES: Tophi deposits are a well-known cause of joint destruction, gouty nephropathy and spinal cord compression. This study reports another major complication of gout, namely tophi deposition causing limited knee joint excursion. methods: Seven gout patients with limited knee joint excursion owing to tophi deposition were studied to reveal clinical features and magnetic resonance imaging (MRI) findings. None of the patients were able to assume a full squatting posture. RESULTS: No patients had visible subcutaneous tophi over the knee joints, except for one case in which a pea-sized subcutaneous tophus was noted. Additionally, two patients even lacked visible tophi elsewhere. All knee problems in the study group were initially regarded as being due to degenerative or other internal derangements, but MRI unexpectedly revealed multiple tophaceous depositions within and around the joint. CONCLUSIONS: Intra-articular and periarticular tophi limiting knee joint range of motion are a rare but important cause of walking disability in gout patients. Although most patients do not display visible subcutaneous tophi over the knee on physical examination, the differential diagnosis should consider intra-articular tophi and MRI is valuable in this clinical setting.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
4/7. Polyarticular symmetric tophaceous joint inflammation as the initial presentation of gout.A 76-year-old woman suffered from bilateral distal index finger pain and swelling. The patient had been initially treated with antibiotics for herpetic whitlow complicated by a secondary bacterial infection. gout was diagnosed through clinical history, physical examination and identification of monosodium urate crystals in the joint aspirate. gout appearing as polyarticular, symmetric tophi involving the periungual region and distal interphalangeal joint has not been previously described.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
5/7. Rheumatologic conditions of the wrist.With the exception of the arthritis associated with rubella, acute wrist conditions have no pathognomonic physical findings. The primary physician can diagnose and treat the majority of wrist problems presented. Referral to a rheumatologist is necessary only when confronted with an anxious patient or an individual having persistent wrist pain and swelling of obscure etiology. This article focuses on rheumatologic problems of the wrist that are most likely to come to the attention of the primary physician.- - - - - - - - - - ranking = 0.085591158588473keywords = physical (Clic here for more details about this article) |
6/7. A 77-year-old man with right anterior knee pain. Intraosseous gout of the patella.The following case is presented to illustrate the roentgenographic and clinical findings of a condition of interest to the orthopaedic surgeon. Initial history, physical findings, and roentgenographic examinations are found on the first two pages. The final clinical and roentgenographic differential diagnoses are presented on the following pages.- - - - - - - - - - ranking = 0.085591158588473keywords = physical (Clic here for more details about this article) |
7/7. indomethacin-induced behavioral changes in an elderly patient with dementia.OBJECTIVE: To describe a case of behavioral changes induced by indomethacin in an elderly man with a history of senile dementia of the Alzheimer type. CASE SUMMARY: A 92-year-old white man with a history of senile dementia of the Alzheimer type, glaucoma, and constipation was treated with indomethacin for an episode of pseudogout. After six doses of indomethacin 25 mg, the patient became very agitated, confused, and was physically and verbally aggressive to the nurses. indomethacin was discontinued and the patient recovered after receiving haloperidol 0.5 mg/d p.o. over a period of 10 days. DISCUSSION: Only a few cases of psychosis have been reported in the literature concerning the use of indomethacin in patients over the age of 60 years. The mechanism by which indomethacin causes psychosis is not well understood, but it is postulated that the acute psychosis may be related to the similarity between the molecular structure of indomethacin and serotonin. Both indomethacin and serotonin have an indolic moiety, which may explain the development of acute psychosis in this patient. CONCLUSIONS: Healthcare providers should be aware that patients with a history of dementia who are receiving indomethacin may be at risk of developing severe behavior problems along with gastrointestinal and renal adverse effects.- - - - - - - - - - ranking = 0.085591158588473keywords = physical (Clic here for more details about this article) |