J Korean Soc Spine Surg.  2018 Mar;25(1):18-23. 10.4184/jkss.2018.25.1.18.

Tophaceous Gout of the Lumbar Spine Mimicking Infectious Spondylodiscitis and Epidural Abscess

• Jeong JS
• Jeong HT
• Lee IS
• Woo YH

• KMID: 2408303
• DOI: http://doi.org/10.4184/jkss.2018.25.1.18

Abstract

STUDY DESIGN: Case report
OBJECTIVES
We report a case of surgically proven tophaceous gout of the lumbar spine at the L5-S1 level in a 43-year-old man that mimicked infectious spondylodiscitis and epidural abscess on magnetic resonance (MR) images. SUMMARY OF LITERATURE REVIEW: Some patients have chronic back pain with an epidural mass. Among the many causes of epidural masses, tophaceous gout of the lumbar spine is very rare.
MATERIALS AND METHODS
A 43-year-old man presented with fever and chronic back pain with radiating pain. In an MR image of L4-5, an abnormal subcutaneous mass was found in the posterior epidural space. The subcutaneous mass was isointense on T1-weighted images compared with the intervertebral disc, and focally and strongly hyperintense and heterogeneous on T2-weighted images. After the intravenous administration of gadolinium contrast, the mass was fairly homogenous, with a low signal intensity and without enhancement. With the diagnosis of infective spondylitis with epidural abscess, we performed a decompressive mass resection.
RESULTS
The pathologic examination revealed multinuclear giant cells and amorphous crystalline fibrous tissue. The lesion was diagnosed as tophaceous gout.
CONCLUSIONS
This case underscores the importance of considering tophaceous gout in the differential diagnosis of an epidural mass in a patient with chronic back pain.

Keyword

Gout; Epidural abscess; Magnetic resonance imaging

MeSH Terms

Administration, Intravenous
Adult
Back Pain
Crystallins
Diagnosis
Diagnosis, Differential
Discitis*
Epidural Abscess*
Epidural Space
Fever
Gadolinium
Giant Cells
Gout*
Humans
Intervertebral Disc
Magnetic Resonance Imaging
Spine*
Spondylitis
Crystallins
Gadolinium

Figure

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  Fig. 1. Enhanced sagittal magnetic resonance imaging (MRI) (A). Enhanced axial MRI shows a lesion mimicking an epidural abscess (B).

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  Fig. 2. After laminectomy, gout tophi were found (A). The epidural area was decompressed and the gout tophi were removed (B).

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  Fig. 3. Postoperative sagittal magnetic resonance imaging (A). After decompressive surgery, the thecal sac had expanded (B).

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  Fig. 4. Multiple granulomas composed of inflammatory cells (macrophages, lymphocytes, plasma cells, and giant cells) surrounding the area of crystals (A, ×40; B, ×200).

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