Chronic tophaceous gout with anti-CCP positivity: A rare presentation

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Chronic tophaceous gout with anti-CCP positivity: A rare presentation

A 45-year-old male patient was referred to the clinic with a history of walking inability due to pain in both feet and knees since 1 month. He had typical episodic pain in the 1st metatarsophalangeal (MTP) joint since 10 years, which responded well to NSAIDs. His history revealed a previous hospital admission for reduced urine output and pedal edema. His abdominal ultra-sonography showed multiple tiny non-obstructive calcifications in the renal calyx with normal-sized kidney. Though the initial creatinine level reported was 2.2 mg/dl, it stabilized within one week. A diagnosis of analgesic nephropathy was made and was asked to avoid NSAIDs. However, the patient subsequently presented with poly-articular arthritis and nodules over the elbows and the MTP joints. Needle aspiration of the nodules revealed white chalky aspirate suggestive of tophi. X-ray of the feet showed punched-out erosions suggestive of gout. The multiple non-obstructive calcifications noted were suggestive of urolithiasis with grade 1 renal parenchymal changes, indicative of acute renal injury. The patient initially had episodic gout, which later developed into chronic tophaceous gout with gouty nephropathy and urolithiasis. The patient was started on colchicine 0.5 mg, short course of oral steroids for pain, and hydroxychloroquine 200 mg twice daily.

The most likely diagnosis of this presentation is:

  • Gout

  • Tophaceous gout with nephropathy

  • Arthritis

  • Rheumatoid Arthritis (RA)

  • Osteoarthritis

Introduction:

Tophaceous gout normally affects the regions like great toe, olecranon, and hand. It is difficult to differentiate RA and tophaceous gout, as the conditions such as morning stiffness, symmetrical distribution and positive rheumatoid factor are seen in both. The present study highlights the rare presentation of chronic tophaceous gout with anti-cyclic citrullinated peptide (anti-CCP) positivity, which progressed to gouty nephropathy and urolithiasis.

Medical history:

Patient had typical episodic pain in the first metatarsophalangeal (MTP) joint since 10 years, which responded well to NSAIDs. His history revealed a previous hospital admission for reduced urine output and pedal edema.

Examination and laboratory investigation:

A diagnosis of analgesic nephropathy was made and was asked to avoid NSAIDs. However, the patient subsequently presented with poly-articular arthritis and nodules over the elbows and MTP joints. Needle aspiration of the nodules revealed white chalky aspirate suggestive of tophi. The results of lab investigations are also given. X-ray of the feet showed punched-out erosions suggestive of gout. The multiple non-obstructive calcifications noted were suggestive of urolithiasis with grade 1 renal parenchymal changes, indicative of acute renal injury. The patient initially had episodic gout, which later developed into chronic tophaceous gout with gouty nephropathy and urolithiasis.

Table 1: Results of clinical and lab investigations

Treatment:

The multiple non-obstructive calcifications noted were suggestive of urolithiasis with grade 1 renal parenchymal changes, indicative of acute renal injury. The patient initially had episodic gout, which later developed into chronic tophaceous gout with gouty nephropathy and urolithiasis. The patient was started on colchicine 0.5 mg, short course of oral steroids for pain, and hydroxychloroquine 200 mg twice daily. Further follow-up showed that patient had become asymptomatic and the tophi had reduced in size. His renal functions had become normal.

Discussion:

Tophaceous gout is a rare clinical manifestation, which seldom co-exist with RA. Literature review shows very few cases of co-existence. If the patient has polyarticular involvement with nodule formation, it is difficult to differentiate RA with rheumatoid nodules from tophaceous gout. In such cases, examining the nodule aspirate may help to differentiate the conditions. Rheumatoid factor, which is generally considered as a serological marker of RA, may appear positive in some elderly healthy patients and also in other rheumatic and non-rheumatic diseases. Anti-CCP antibodies is documented to be highly specific in diagnosing RA in contrast to RF, and it is rarely reported in patients with gout. Though anti-CCP was positive in the current case, the patient did not show any specific symptoms of RA. In addition, it should be noted that the RA had not been progressed for the past ten years and the patient was asymptomatic in between episodic occurrence of the disease. Ultrasound examination of the elbows, wrists and knees was normal. Based on the clinical examination, examination of aspirated material, and typical presentation of erosions in the 1st MTP joints the patient was diagnosed to have chronic tophaceous gout.

A similar case study by Sarmento et al. has reported a rare presentation of polyarticular tophaceous gout with atypical involvement of the joints of the hands and diffuse subcutaneous nodules. Based on thorough clinical examination and further evaluation, the diagnosis was concluded as mutilating gout mimicking RA.

The study by Bas et al. has concluded that the anti-CCP, though more specific than RF, cannot be considered as a definite test for the determination of co-existence of gout and RA. In one such study, authors could identify only one patient with anti-CCP and RF positivity, out of 7 cases with co-existing gout and RA. In certain cases, dual-energy CT of the affected joints and nodules may help to detect the presence of uric acid crystals.

Learning:

The present study also highlights the need of careful diagnosis to distinguish RA from polyarticular gout and the necessity to consider multiple diagnostic factors including the detection of serological markers, the presence of tophi, and the characteristic appearance of gouty erosions. Among the serological markers, anti-CCP may appear positive in other rheumatic disorders, hence careful interpretation of the findings in conjunction with evaluation of clinical history is warranted.

References:

  1. Dhoat PS, Khurana A, Mittal J, Sandhu AK, Singh S. Coexistent tophaceous gout and rheumatoid arthritis. A case report. Journal of Evolution of Medical and Dental Sciences. 2014; 3(14): 3685-3688.

  2. 2. Sarmento JF, Cavalcante V de A, Sarmento MTR, Braz A de S, Freire EAM. Chronic tophaceous gout mimicking rheumatoid arthritis. RevistaBrasileira de Reumatologia. 2009 Dec;49(6):741–6.

  3. 3. Bas S, Perneger TV, Seitz M, Tiercy JM, Roux-Lombard P, Guerne PA. Diagnostic tests for rheumatoid arthritis comparison of anti-cyclic citrullinated peptide antibodies, anti-keratin antibodies and IgM rheumatoid factor. Rheumatology 2002; 41:809-14.

  4. 4. Puszczewicz M, Iwaszkiewicz C. Role of anti-citrullinated protein antibodies in diagnosis and prognosis of rheumatoid arthritis. Arch Med Sci. 2011 Apr;7(2):189–94. Dhoat PS, Khurana A, Mittal J, Sandhu AK, Singh S. Coexistent tophaceousgout and rheumatoid arthritis. A case report. Journal of Evolution of Medical and Dental Sciences. 2014; 3(14): 3685-3688.

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