Flexor tendinitis and median nerve compression caused by gout in a patient with rheumatoid arthritis

Coexistent digital gouty and infective flexor tenosynovitis

Flexor tenosynovitis of the hand is often caused by trauma or infection. Gouty tenosynovitis is an uncommon presentation of the condition and is usually misdiagnosed as infection with the patient undergoing surgery. The coexistence of infection and gout causing flexor tenosynovitis has never been described before in the literature; we report the first ever case and emphasise the importance of its awareness for optimal treatment. A 54-year-old man was initially diagnosed and treated as having infective flexor tenosynovitis and, later, due to a lack of improvement in his symptoms, was discovered to also have gout. We review the literature and suggest management strategy for use in daily clinical practice, including an algorithm, for this presentation.

Finger Flexion Contracture: First Manifestation of Gout

Introduction:

Tophi can present as a first sign of hyperuricemia but literature has limited reports as far as flexor tendon contracture presenting as a first clinical sign of gout is concerned. We report a case of tophaceous gout with finger flexion contracture as its first sign.

Case Report:

A 45 years old man presented in our out patient department with complaint of inability to extend middle finger of his left hand along with a mass growing over volar aspect of forearm for over few months. On physical examination a firm – hard mass around 2*2 cm was found over volar aspect of forearm just proximal to flexor retinaculam. MRI showed mass within tendon of FDS. Clinical suspicion of TB tenosynovitis, was kept as a first diagnosis followed by soft tissue neoplasm and subsequently surgical exploration was performed. A whitish chalky infiltration of tendon of FDS, synovial adhesion of other tendons along with median nerve embedded within hypertrophied synovium of flexor tendon noted. Patient underwent synovectomy and excision of tendon of FDS to middle finger Following histo-pathological evaluation a diagnosis of tophaceous gout was made with serum uric acid level being 8.6 mg/dl.

Conclusion:

A review of the literature reveals that gouty arthritis of the wrist is rare in isolation. Gout at the wrist as the initial appearance of the condition occurs between 0.8 to 2% of all gout cases. Gout occurs when serum uric acid levels are persistently higher than 6.8mg/dl. Since tophaceous gout can be seen scarcely in well controlled hyper-uricaemic patient thus making preoperative diagnosis of intratendinous tophi even more strenuous.

Hyperparathyroidism-related extensor tenosynovitis at the wrist: a general review of the literature

Extensor tenosynovitis often occurs accompanying with rheumatoid arthritis, gout, trauma, mycobacterium and dialysis-related amyloidosis. However, there is no recognition of extensor tenosynovitis accompanying with hyperparathyroidism. The purpose of this general review was to describe the clinical condition and to report the results of surgical intervention in the extensor tenosynovitis at the wrist related to hyperparathyroidism. Hyperparathyroidism is thought to be a rare disease in adult. Although renal symptoms are the commonest symptom, musculoskeletal complaints also occur in hyperparathyroidism. From our general review, hyperparathyroidism deserves consideration in the differential diagnosis of extensor tenosynovitis at the wrist.

The broad spectrum of urate crystal deposition: unusual presentations of gouty tophi

OBJECTIVES

Gout is typically described as an inflammatory arthropathy that affects the peripheral joints. Our aim was to describe atypical and rare clinical presentations of gouty tophi to help increase physician awareness and aid in patient care.

METHODS

The relevant English literature of unusual gout manifestations was searched using the keywords gout, toph*, monosodium urate, uric acid, unusual, and rare. Well-described case reports, case series, and review articles were evaluated and included, if relevant, in the literature review.

RESULTS

Review of the literature revealed many unusual manifestations of gouty tophi involving the head and neck, skin, viscera, bones, tendons, ligaments, nerves, and axial skeleton. Transplant recipients, women, and elderly people are particularly susceptible to developing tophi. Furthermore, gout can cause diagnostic dilemmas, as it can be a great mimicker of and can coexist with infection, malignancy, and other connective tissue diseases. Imaging modalities can help detect tophi in atypical locations.

CONCLUSIONS

Tophi can present in unexpected locations, even as the first sign of gout, and vigilance is required when unusual symptoms or signs occur in a patient with gout.

Carpal tunnel syndrome and finger movement dysfunction caused by tophaceous gout: a case report

We describe a case of tophaceous gout with a combination of carpal tunnel syndrome and finger movement dysfunction. Carpal tunnel syndrome secondary to gout is uncommon. The concomitant presence of finger movement dysfunction is rare and suggests the involvement of the flexor tendons inside the carpal tunnel. Surgery is recommended to decompress the median nerve, to confirm the diagnosis, and for immediate improvement of flexor tendon excursion. Our patient's finger movement improved dramatically soon after surgery.

Acromegaly as a cause of trigger finger

We report a trigger finger of the right index finger in a 28-year-old man with acromegaly, in which condition growth hormone increases extracellular volume by stimulating sodium reabsorption in the distal nephron. The increase in extracellular fluid can cause oedematous swelling of the flexor synovium in the digital sheath.

Atypical triggering at the wrist due to intratendinous infiltration of tophaceous gout

This is a report of a 41-year-old male with triggering of the long finger flexor digitorum superficialis tendon at the wrist secondary to tophaceous gout. The tophus was severely infiltrating the tendon, and a tenotomy of the FDS tendon was performed. Preoperatively, the lesion could not be distinguished from a neoplasm.

Gout affecting the hand and wrist

Tophaceous gout in the hand and wrist often presents de novo as the first sign of the disease process in the elderly. Tophaceous material may present in a liquid, pasty, or chalky/granular state. Treatment may be as simple as aspirating the liquid or squeezing out pasty tophaceous material. Other nonsurgical treatment options include lifestyle and dietary modifications and drug therapy. Surgery is often indicated for the patient with significant tendon and joint compromise as well as skin breakdown and for decompression of compressive peripheral neuropathy.

Les tendons : lésions inflammatoires et dégénératives

Tendons may be affected by a variety of pathologic conditions, including those caused by overuse and inflammatory diseases. Sonography is a very sensitive means of detecting tendonous pathology because of its spatial resolution and its comparative and dynamic capabilities. Moreover its wide availability makes it the preferred first-line imaging modality in these cases. This paper reviews the inflammatory and degenerative conditions that may involve the tendons and their sonographic appearances.

Sonography in wrist tendon pathology

Wrist tendons may be affected by a variety of pathologic conditions, including those caused by trauma and overuse, inflammatory and metabolic disorders, or infection. Sonography is a very sensitive means of detecting tendinous pathology because of its spatial resolution and its comparative and dynamic capabilities. Its wide availability makes it the preferred first-line imaging modality in the case of wrist pain. This article reviews the pathologic conditions that may involve the wrist and their sonographic appearances.

Gouty flexor tenosynovitis of the digits: report of three cases

Gouty tenosynovitis in the hand is a rare entity. To date the limited cases described have involved predominantly extensor tendons in the fingers and flexor tendons in the palm or wrist. Flexor tendon involvement is less common and has been reported only twice to our knowledge distal to the palm. We report 3 cases of extra-articular gout presenting as tophaceous involvement of flexor tendons in the fingers. All cases were treated surgically. These cases are presented to heighten awareness of this rare entity and to provide a setting for a discussion of management.

Gout and hyperuricemia

Gout continues to be a health problem around the world despite the availability of effective therapies. Although the prevalence is influenced by genetic factors, the associations of alcohol consumption, obesity, and hypertension appear to be partially responsible for the increased prevalence of gout and hyperuricemia in African and Oriental countries. The association between hyperuricemia and cardiovascular disease seems linked to insulin resistance. This relation, in part, explains the common coexistence of hyperlipidemia and glucose intolerance in patients with gout. Accordingly, it is recommended that one pay more attention to dietary manipulation in patients with gout in addition to managing hypertension, obesity, and other medical problems. Although acute gout attacks can be treated, eliminating gout requires effective removal of urate from the body. Allopurinol remains a dominant urate-lowering agent, however its use may be limited by allergic reactions. Uricosuric agents are also effective urate-lowering agents and provide an alternative to allopurinol. Strategies to treat patients who are sensitive to allopurinol continue to evolve.