Case of gout with inflammatory low back pain

A 50-year-old male patient with a history of chronic tophaceous gout presented with low back pain and bilateral shoulder, hip, knee, and buttock pain for 1 year. He had nocturnal exacerbations of buttock pain and significant early morning stiffness, which improved with nonsteroidal anti-inflammatory agents (NSAIDs). On examination, he had multiple hard, lobulated tophaceous deposits over the bilateral elbow, hand, leg, and foot. There was no ulcer or discharge from tophi (Figure 1A). He had restriction of movements in the lower back and bilateral positive faber test localized to the back. His medical history included gout, which was detected 13 years ago. He had recurrent episodes of pain in the first metatarsophalangeal joints, ankles, knees, shoulders, and hand joints. For the past 12 years, he noted firm to hard swellings in both forearms, hands, legs, and feet. Few were painful to touch. There was no discharge or ulceration. He was started on Febuxostat and was advised to follow up regularly. However, he defaulted on the treatment and managed recurrent flares with NSAIDs. The symptoms worsened in the past year. His uric acid was 12.4 mg/dL. Radiography showed grade 2–3 sacroiliitis with soft tissue shadow in the right gluteal region (Figure 1B). Magnetic resonance imaging of the pelvis showed T1 hypointense and T2 hetero-intense lesions in the bilateral gluteus maximus (Figure 1C) and normal sacroiliac joint (Figure 1D), suggesting tophi deposition in gluteus muscles. Tophi deposition in unusual sites like the ear, liver, intraosseous, intramuscular, and subcutaneous tissues leading to diagnostic dilemmas has been reported.1 Gouty sacroiliitis due to uric acid deposition in the sacroiliac joint may also present with inflammatory back pain.2 Tophi deposition in gluteus muscle mimicking inflammatory low back pain is unusual. Dual-energy computed tomography (DECT) may be a useful imaging modality in case of uncertainty with a computed tomography scan or magnetic resonance imaging.3 We present this as a case of gouty arthritis with tophi deposition in the gluteus muscle, causing inflammatory back pain. He was restarted on Febuxostat and advised compliance with treatment. Sabarinath Mahadevan drafted the manuscript. Mahabaleshwar Mamadapur critically reviewed it and gave valuable suggestions. All the authors approved the final version of the manuscript. The authors would like to thank the patient for allowing us to publish the case report. The authors declare no conflict of interest. Written informed consent for publication was obtained from the patient. The data that support the findings of this study are available on request from the corresponding author.