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| IMAGES IN RHEUMATOLOGY |
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| Ahead of print publication |
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Severe entheseal involvement in a patient with gout
Kunal Chandwar, Prasanna Dogga, Digvijay Gajanan Ekbote, Kriti Kishor, Juhi Dixit, Puneet Kumar
Department of Clinical Immunology and Rheumatology, King George's Medical University, Lucknow, Uttar Pradesh, India
| Date of Submission | 03-Nov-2021 |
| Date of Acceptance | 17-Nov-2021 |
| Date of Web Publication | 11-Feb-2022 |
Correspondence Address:
Kunal Chandwar,
Department of Clinical Immunology and Rheumatology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/injr.injr_255_21
Keywords: Enthesitis, enthesophyte, gout
A 54-year-old male presented with complaints of pain in the ankle, knee, and elbow joints. The complaints started 4 years back with monoarticular episodic pain and swelling of the left first MTP, left ankle, and left knee, which lasted for a few days, and there was a complete response to nonsteroidal anti-inflammatory drugs (NSAIDs). Over the past 6 months, the pain has increased with swelling over both ankle, knee, and elbow joints. The patient is nonalcoholic and nonsmoker and has no history suggestive of psoriasis, inflammatory bowel disease, uveitis, or dactylitis. There was no history of similar complaints in the family. On examination, there was tenderness over the olecranon process, Achilles tendon insertion, and the tibial tuberosity without any swelling or tenderness of the ankle, knee, or elbow joints. X-ray of the knees, ankle, and elbows [Figure 1]a [Figure 1]b [Figure 1]c suggested enthesophytes over the inferior border of the patella and tibial tuberosity [Figure 1]a, Achilles tendon and plantar facia insertion [Figure 1]b and triceps tendon insertion over the olecranon process [Figure 1]c. | Figure 1: Lateral X-rays of knee (a) ankle (b) and elbow (c) showing enthesophyte formation at the insertion sites of the patellar tendon, Achilles tendon, and triceps tendons. Tophus at 1st MTP joint as seen on musculoskeletal ultrasound. (d) Multiple negatively birefringent monosodium urate crystals on polarized microscopy. (e) Musculoskeletal ultrasound findings: thickened tendon with irregular cortical bone. (f) and increased vascularity at the insertion of tendoachillis. (g) suggestive of active enthesitis. Double contour sign at the knee joint (h).
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Musculoskeletal ultrasound of the joints suggested active enthesitis with thickened tendons, increased vascularity, and irregular cortical bone at the site of insertion, especially at the insertion of the Achilles tendon [Figure 1]f and [Figure 1]g. Ultrasound of the knee was suggestive of a double contour sign [Figure 1]h, and of the 1st left MTP suggested a Tophi overlying the MTP joint [Figure 1]d. The contents were aspirated and visualized under the microscope to confirm the presence of multiple negatively birefringent needle-shaped crystals [Figure 1]e suggestive of gout. The serum uric acid levels were elevated (7.9 mg/dl). The patient was started on allopurinol and NSAIDs.
Although gout has been known to be associated with enthesitis,[1] such extensive enthesitis leading to enthesophyte formation without any active joints is rarely seen in clinical practice.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Xu G, Lin J, Liang J, Yang Y, Ye Z, Zhu G, et al. Entheseal involvement of the lower extremities in gout: An ultrasonographic descriptive observational study. Clin Rheumatol 2021;40:4649-57.  |
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