Gouty Panniculitis also Involving the Bone Marrow

Abstract

Gout is a clinical syndrome presenting with recurrent, painful arthritis caused by deposition of monosodium urate. Urate crystal deposits are usually detected in the synovial membranes, joint capsules, articular cartilage, and periarticular tissue, and, rarely, in extra-articular areas (1). Gouty patiniculitis is characterized by subcutaneous depositions of urate crystals with lobular panniculitis. We report here a case of this rare variant of gout, in a 47-year-old man who also showed characteristic depositions of crystals in the bone marrow. CASE REPORTA 47-year-old man presented with skin-coloured to brownish subcutaneous nodules and plaques on both extremities, both hands, and the joints of the foot for 3^ years. He complained of pain, but denied pruritus or any other symptoms. He had had hypertension and had been treated with isosorbide-5-mononitrate 50 mg, daily for 10 years. In addition, he had undergone haemodialysis for end-stage renal disease for 8 years. He also underwent amputation of all of his toes due to thromboangitis obliterans 2 years previously. He had recently been diagnosed with hypothyroidism and took 100 \ig per day levothyroxine sodium (Synthyroxine®, Darim, Seoul, Korea). On physical examination, multiple, various sized, oval-to-linear, firm, fixed, subcutaneous papules, nodules, and plaques were found (Fig. 1). In addition, his skin showed a sclerotic appearance and his joints were not fully extendable. His red blood cell count was 2.32 X lO'/l and white blood cell count was 2.3 x lOVl, with 74.3% neutrophil segments, mild anaemia and neutropaenia. Blood urea nitrogen and uric acid levels were within normal limits (23 mg/dl and 4.2 mg/dl, respectively, upper normal limit 24 and 4.5 mg/dl, respectively). However, creatinine level was markedly elevated (4.6 mg/dl) and levels of iron and total iron-binding capacity were decreased (38 ng/dl and 95 |ig/dl, respectively). Other haematological and autoimmue markers, including antinuclear antibody, rheumatic factor, antimicrosomal antibody, and extractable nuclear antigen profiles, were not remarkable. A biopsy specimen showed that fine, needle-shaped. Fig.

Gouty Panniculitis with Ulcerations in a Patient with Multiple Organ Dysfunctions

“…Some patients, who have a normal uric acid level at diagnosis, may have experienced long-term hyperuricemia at an earlier time. Among all 18 cases, abnormal renal function was noted in 12 (66.7%) patients [1, 6, 8, 9, 17, 18]. Due to the lack of complete metabolic panel (CMP) data, renal function in the remaining 6 cases could not be assessed [2, 7, 19].…”

Bone marrow imprints of crystal‐storing histiocytosis

“…The differential diagnosis of bone marrow cytologic preparations with numerous histiocytes and crystals includes, in addition to CSH, other conditions characterized by the presence of intracellular and extracellular crystals, such as oxalosis, silicosis, cystinosis and gout, and other proliferations of large histiocytes with intracytoplasmic crystalline and noncrystalline material. Oxalate, cystine, silica and urate crystals, as well as crystals of clofazimine (an antimycobacterial drug used in the treatment of leprosy) and Charcot‐Leyden crystals have all been described in the bone marrow, but have different staining characteristics, occur in different clinical contexts and are frequently accompanied by a foreign body or granulomatous reaction (Table ). Disseminated atypical mycobacterial infection can show abundant macrophages with negatively‐staining organisms that may mimic CSH, as can Gaucher cells with their abundant wrinkled‐paper‐like cytoplasm, and pseudo‐Gaucher cells seen in chronic myelogenous leukemia.…”

Effects of hyperuricemia on the skin

“…Diagnostyka różnicowa dnawego zapalenia tkanki podskórnej obejmuje zapalenie tkanki podskórnej spowodowane osadzaniem się wapnia, amyloidu i szczawianów [41].…”

“…Niektóre doniesienia opisują poprawę zmian skórnych po leczeniu hiperurykemii dużymi dawkami allopurynolu 600-1200 mg/dobę w połączeniu z kolchicyną [41,43].…”