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Concomitant gout and rheumatoid arthritis - A case report

Article in Indian Journal of Medical Sciences · September 2004

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Sir Ganga Ram Hospital
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 349 350 INDIAN JOURNAL OF MEDICAL SCIENCES

CASE REPORT consulted various practitioners and took

allopathic and indigenous medications but to
no relief. Two months prior to admission he
CONCOMITANT GOUT AND RHEUMATOID ARTHRITIS - A CASE presented with multiple nodular swellings on
feet, hands, wrists and elbows. Patient’s past
REPORT
medical history is significant for hypertension,
POOJA KHOSLA*, ATUL GOGIA**, P. K. AGARWAL***, AMIT PAHUJA**,
SUNIL JAIN***, K. K. SAXENA# diabetes mellitus, chronic ethanolism and renal
stones for which he underwent left
nephrectomy about 25 years ago. Family
Abstract history is non-contributory.
Figure 1: Multiple nodules present on metatarsal joints
of both feet (Gouty Tophi)
We report a case of definite rheumatoid arthritis and co-existing gout. Although gout On examination multiple nodules were present
and rheumatoid arthritis are relatively common entities individually, the co-existence on metatarsal joints of both feet, Achilles
of these two conditions is rare. tendon bilaterally, left prepatellar bursa,
bilateral metacarpophalangeal joint, right
KEY WORDS: Gout, Rheumatoid Arthritis olecranon process. There was swelling and
tenderness of PIP and MCP joints of both feet.
(Figure 1) Laborator y data revealed
INTRODUCTION metatarsophalangeal joint. He had hemoglobin - 8.9gm/dl, ESR 124 mm at the
asymmetrical joint pains and swelling at end of first hour, leucocyte count 7400/cmm
Gout and rheumatoid arthritis rarely co-exist in irregular intervals with exacerbations and with normal differential count. Random blood
the same patient. As separate disease entities remissions. The symptoms subsided in sugar was 139 mg/dl, Creatinine- 1.6 mg/dl;
they are relatively common. Rheumatoid between but there was no period when patient serum uric acid level was 10.9 mg/dl. His 24
Figure 2: X-ray both hands showed subarticular
arthritis affects 2-3% of the population1 with a was completely pain free. He did not have hour urinary uric acid excretion was 446 mg/ erosions at distal end of radius, ulna, Scaphoid,
female to male ratio of 3:1, while gout affects associated warmth and erythema although dl. Serum calcium, phosphorus, LFT, radial aspect of 2nd and 3rd proximal
interphalangeal joint bilateral and left triquetral with
0.25% of the population, with 90% of the cases swelling and tenderness were present. Three electrolytes and lipid profile were normal. associated soft tissue swelling
occurring in males.1 It has been reported that years after onset of joint pains, patient started Serum iron was 7 mg/dl, TIBC 244 mg/dl. Stool
there is a strong negative correlation between having pain in small joints of hands, knees, for occult blood was negative. Rheumatoid femoral and patello-femoral joint space with
rheumatoid arthritis and gout.2 ankles, shoulders and elbows, with early factor was 2560 iu/ml (by latex agglutination subarticular lytic area, sclerosis and soft tissue
morning stiffness lasting for more than four method) and CRP was 96 mg/dl. X-rays of both swelling bilaterally right more than left. These
CASE HISTORY hours. Joint pains were incapacitating and he feet showed multiple lytic areas in 2nd and 3rd findings were suggestive of gout lus
had to quit his job. Initially pain was localized metatarsal and tarsal bones. X-rays of both rheumatoid arthritis. X-ray pelvis showed
A 55-year-old ex-army man was admitted with to the ankles and left 1st metatarsophalangeal elbows showed soft tissue swelling at bilateral sacroiliitis. Sonography of the
a 10-year history of pain in the ankle joints joint but gradually went on to involve the rest olecranon process, right more than left. X-rays abdomen revealed mild hepatomegaly with
followed by involvement of left 1st of the joints over the next 7 years or so. He of both hands showed subarticular erosions at grade I fatty changes with right kidney 12.4x4.6
distal end of radius, ulna, scaphoid, radial cm in size. Thick chalky white fluid was
aspect of 2nd and 3rd proximal interphalangeal aspirated from the nodular swelling at the right
Correspondence:
*Registrar, ***Consultant, **Resident-Department of Dr. Atul Gogia, Resident, Department of Medicine, J-6/27 joints bilaterally and left triquetrum with metatarsophalangeal joint. It was alkaline with
Medicine, #Consultant, Department of Radiology, Rajouri Garden, New Delhi - 110 027. India. associated soft tissue swelling (Figure 2). X- numerous polymorphs, WBC 25000 cells/cmm,
Sir Ganga Ram Hospital, Rajinder Nagar, E-mail: atulgogs@rediffmail.com
New Delhi - 110060, India. ray of both knees revealed reduced tibio- 90% polymorphs and 10% lymphocytes with

Indian J Med Sci Vol. 58 No. 8, August 2004 Indian J Med Sci Vol. 58 No. 8, August 2004
 CONCOMITANT GOUT AND RHEUMATOID ARTHRITIS
monosodium urate crystals with birefringence.
Patient underwent arthroscopy of the right
knee and synovial biopsy was taken.
Ar throscopic finding revealed synovial
hypertrophy with gouty crystals embedded and
spread everywhere in the joint. Synovial biopsy
was compatible with gouty tophi in synovium
along with rheumatoid nodule like structure
(Figure 3). Diagnosis of chronic tophaceous
gout with rheumatoid arthritis was made and
the patient was star ted on colchicine,
allopurinol and methotrexate.
DISCUSSION
The co-existence of gout and RA may be
supported by both clinical and laboratory
criteria.3
Our patient had recurrent gouty attacks
superimposed by rheumatoid arthritis. He had
high serum uric acid; monosodium urate
deposit in subcutaneous nodules, high titer of
RF, radiographic changes of gout and erosive
RA and histological evidence of a rheumatoid
arthritis. These manifestations have been
proposed as the criteria for the coexistence of
both diseases.4 A literature review revealed 17
patients with concomitant gout and RA.3,5 The
difficulty of reaching a diagnosis of coexistence
of both diseases may be due to the fact that it
takes time to establish definite evidence of
gout clinically as chronic tophaceous gout
mimics rheumatoid arthritis, so a clinician does
not suspect the condition. RA or their
concurrence. Many features of gout during the
evolution of the disease may mimic RA (We
would like to tell that we are not talking about
acute gout but it is chronic tophaceous gout
and it has a similar course i.e. insidious and
351
Figure 3: Synovial biopsy showing gouty crystals along
with rheumatoid nodule like structure.
gradually progressive.) or vice versa. In all
cases in which gout and RA were associated
no difficulty was encountered in establishing
the diagnosis of gout.2 Papers in the literature
clearly document the presence of gout but rely
on the presence of mor ning stiffness,
symmetrical synovitis and positive RF with low
or high titer for the diagnosis of RA.2 Morning
stiffness and fusiform swelling of PIP and MCP
joints, though suggestive of RA, are misleading
since these findings can occur in polyarticular
tophaceous gout. It has been reported that
chronic synovitis in gout may also simulate RA
when studied by means of arthrography.2 The
presence of lymphocytic infiltration with
germinal centers and the absence of crystals
in the chronic synovitis support the diagnosis
of RA.2 and a high incidence of positive test
for RF has been reported in gout without
clinical evidence of RA. Kozin and McCarty1
found 30% of patient with chronic topahceous
gout and 10% of patients with acute gout to
have rheumatoid factor present in low titers
(<1:320). Other researchers also found positive
titers of RF, but in a smaller percentage of
patients. 6 In our case, the pathological
changes present, in the synovial membrane
Indian J Med Sci Vol. 58 No. 8, August 2004
352 INDIAN JOURNAL OF MEDICAL SCIENCES
and the high titer of RF (1:2560) support the
diagnosis of RA beyond doubt. Unusual feature
observed in our patient was bilateral sacroilitis.
This is an uncommon finding, seen in
rheumatoid arthritis.7 There is no clear data on
Sacroilitis in gout but cases showing sacroilitis
in gout have been reported (Reference: Talbott
JH, Altman RD, Yu TF. Gouty ar thritis
masquerading as Rheumatoid ar thritis.
Seminars in Arthritis and Rheumatism 1978;
8(2): 100-101.
We agree with Atdijian and Fernandez and
Rizzoli et al2,6 that diagnosis of this coexistence
can be made with certainty by finding the
histological evidence of rheumatoid nodules
and monosodium urate crystal deposition.
Synovial biopsy from right knee in our patient
had changes of gout and rheumatoid arthritis.
The fixation of biopsy materials in alcohol is
important since granulomas with histologic
features resembling rheumatoid nodules or
rheumatoid synovitis may show crystals of
MSU when examined under contrast polarizing
light microscope.2 After a confirmed diagnosis,
treatment with Disease modifying drugs along
with hypouricemic therapy can be safely
Indian J Med Sci Vol. 58 No. 8, August 2004
started.
REFERENCES
1. Spector AK, Christman RA. Arthritis. Journal of
the America Podiatric Medical Association
1989;79:552-8.
2. Atdjian, Fernandez-Madrid F. Coexistence of
chronic Tophaceous Gout and Rheumatoid
Arthritis. J Rheumatol 1981;8:989-92.
3. Martinez-Cordero E, Bessudo-Babani A, Perez
SCT, Guillermo-Grajales E. Concomitant Gout
and Rheumatoid Ar thritis. J Rheumatol
1988;15:1307-11.
4. Wallace DJ, Klinenberg JR, Morhaim D,
Berlanstein B, Biren PC, Callis G. Coexistent
Gout and Rheumatoid Arthritis. Arthritis and
Rheumatism. 1979;22:81-6.
5. Talbott JH, Altman RD, Yu TF: Gout arthritis
masquerading as rheumatoid arthritis or vice
versa. Semin Arthritis Rheum 1978;8:77-114.
6. Rizzoli AJ, Trujeque L, Bankhurst AD. The
coexistence of gout and rheumatoid arthritis:
Case reports and a Review of Literature. Journal
of Rheumatology 1980;7:316-24.
7. De Carvalho A, Graudal H. Sacroiliac joint
involvement in classical or definite rheumatoid
ar thritis. Acta Radiol Diagn (Stockh)
1980;21:417-23.
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