Images in Clinical Rheumatology
Gouty Arthritis Is Not Everything
No todo es gota
Carmen Carrasco Cubero
, José Luis de la Iglesia Salgado
Corresponding author
Servicio de Reumatología, Hospital del Servicio Andaluz de Salud, Hospital de Jerez de la Frontera, Cádiz, Spain
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"paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "46" "paginaFinal" => "47" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carmen Carrasco Cubero, José Luis de la Iglesia Salgado" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Carmen" "apellidos" => "Carrasco Cubero" "email" => array:1 [ 0 => "maricarmen.carrasco@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "José Luis" "apellidos" => "de la Iglesia Salgado" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Reumatología, Hospital del Servicio Andaluz de Salud, Hospital de Jerez de la Frontera, Cádiz, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "No todo es gota" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 735 "Ancho" => 950 "Tamanyo" => 74451 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Septic arthritis due to <span class="elsevierStyleItalic">S. lugdunensis</span>, with affection of the distal interphalangeal joint of the second finger of the right hand.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 71-year-old male with a history of hypertension in treatment with 20<span class="elsevierStyleHsp" style=""></span>mg/day of enalapril, as well as hyperuricemia, with episodes of monoarthritis of the left foot, without a diagnosis or follow up by Rheumatology.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was admitted due to pain and swelling on the second finger of the right hand and the fourth proximal interphalangeal joint of the left hand, without fever or other clinical data.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination showed Heberden's nodules on both hands, with signs of arthritis on the second distal interphalangeal joint of the right hand, with an accompanying tophus, as well as on the fourth proximal interphalangeal joint of the left hand.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On laboratory tests he presented uric aid of 7.20<span class="elsevierStyleHsp" style=""></span>mg/dl, with a normal blood count, chemistry and acute phase reactants (ESR: 14<span class="elsevierStyleHsp" style=""></span>mm/h, CRP: 0.49<span class="elsevierStyleHsp" style=""></span>mg/dl).</p><p id="par0025" class="elsevierStylePara elsevierViewall">On hand x ray there was evidence of degenerative changes on metacarpophalangeal, interphalangeal, and carpometacarpal joints. The distal interpalangeal joint of the second finger presented soft tissue swelling, with a reduction in joint space and large erosions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Ecocardiography and serial blood cultures were negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Arthrocenthesis of the swollen joint was performed, finding abundant intracellular and extracellular monosodium urate (MSU) crystals under polarized light microscopy, confirming the diagnosis of chronic tophaceous gout.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In addition, surgical drainage of the abscess (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), obtaining a milky fluid. Samples for culture showed growth of <span class="elsevierStyleItalic">Staphylococcus lugdunensis</span> (<span class="elsevierStyleItalic">S. lugdunensis</span>), respondent to betalactamics, macrolides, and quinolones. Treatment with IV cloxacylin was started, lasting 2 weeks (2<span class="elsevierStyleHsp" style=""></span>g/4<span class="elsevierStyleHsp" style=""></span>h).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Progression was favorable, with clinical improvement and culture negativity after onset of treatment with cloxacylin, completed afterward with ciprofloxacyn, 750<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h, for 2 weeks as an outpatient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The association between rheumatoid arthritis and septic arthritis is well known,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> but what is not so well documented is the coexistence of gout and septic arthritis, although there is an increasing number of published clinical cases and case series. In the study by Wallace et al.,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> on preliminary classification criteria for gout, 4% of patients with septic arthritis had coexisting gout (tophi were identified in most cases). In another study by Shah et al.,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> 265 synovial fluid aspirations were analyzed, of which 183 (69%) presented monosodium urate crystals, 81 (30.6%) calcium pyrophosphate crystals, and 1 case (0.4%) where both types of crystals were isolated. The percentage of association of microcrystalline arthritis and septic arthritis was 1.5% (4 cases, of which 3 had pyrophosphate crystals and only 1 case of monosodium urate crystals).</p><p id="par0050" class="elsevierStylePara elsevierViewall">In both situations, it is clinically manifested mainly by joint swelling and pain and it is not always easy to differentiate if the arthritis is due to this or other pathology, especially if there is no clinical evidence of infection. Delay in diagnosis of septic arthritis can cause significant joint destruction.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is important that, even when we make a diagnosis of gout by viewing monosodium urate crystals under polarized light microscopy, the synovial fluid samples are sent for culture and Gram staining,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> especially in cases of tophaceous or severe gout.</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. lugdunensis</span> was described in 1988 by Freney et al.,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and it is a coagulase negative staphylococcus, similar to <span class="elsevierStyleItalic">S. aureus</span>. Its incidence has increased in recent years thanks to its correct microbiological identification. It is usually isolated from skin and soft tissue infections, but has also been reported in cases of native valve endocarditis, breast abscesses, osteomyelitis, peritonitis, lymphangitis, bacteremia, and catheter associated infections.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> It is associated with recurrent infections of prosthetic joints and after procedures such as arthroscopy.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleItalic">S. lugdunensis</span> mainly cause infections in immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Among its virulence factors, the ability of binding to the extracellular matrix protein, fibronectin and fibrinogen stand out.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The sensitivity of ECN to antibiotics depends on the species and origin, whether hospital or community-acquired strain. In our environment, <span class="elsevierStyleItalic">S. lugdunensis</span> has a good sensitivity to beta-lactams. Given the isolation of an ECN and in particular <span class="elsevierStyleItalic">S. lugdunensis</span>, we must be alert to their role as a more aggressive pathogen in immunosuppressed patients.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The focus of our case lies in the importance of synovial fluid samples sent for culture, even when viewing crystals, and the rare isolation of <span class="elsevierStyleItalic">S. lugdunensis</span> in a patient without immune system compromise or previous surgical procedure.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-12-05" "fechaAceptado" => "2011-02-02" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Carrasco Cubero C, De la Iglesia Salgado JL. No todo es gota. Reumatol Clin. 2012;<span class="elsevierStyleBold">8(1)</span>:46–7.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1019 "Ancho" => 750 "Tamanyo" => 68176 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Soft tissue abscess after surgical drainage.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 735 "Ancho" => 950 "Tamanyo" => 74451 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Septic arthritis due to <span class="elsevierStyleItalic">S. lugdunensis</span>, with affection of the distal interphalangeal joint of the second finger of the right hand.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infectious arthritis complicating rheumatoid arthritis other chronic rheumatic disorders" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 17 | 31 |
| 2024 October | 61 | 33 | 94 |
| 2024 September | 58 | 22 | 80 |
| 2024 August | 78 | 31 | 109 |
| 2024 July | 63 | 41 | 104 |
| 2024 June | 60 | 49 | 109 |
| 2024 May | 64 | 36 | 100 |
| 2024 April | 59 | 32 | 91 |
| 2024 March | 59 | 31 | 90 |
| 2024 February | 49 | 59 | 108 |
| 2024 January | 67 | 24 | 91 |
| 2023 December | 50 | 28 | 78 |
| 2023 November | 70 | 47 | 117 |
| 2023 October | 40 | 27 | 67 |
| 2023 September | 95 | 41 | 136 |
| 2023 August | 109 | 31 | 140 |
| 2023 July | 71 | 31 | 102 |
| 2023 June | 94 | 31 | 125 |
| 2023 May | 59 | 23 | 82 |
| 2023 April | 48 | 16 | 64 |
| 2023 March | 89 | 30 | 119 |
| 2023 February | 74 | 32 | 106 |
| 2023 January | 59 | 42 | 101 |
| 2022 December | 66 | 42 | 108 |
| 2022 November | 42 | 43 | 85 |
| 2022 October | 68 | 50 | 118 |
| 2022 September | 58 | 78 | 136 |
| 2022 August | 40 | 68 | 108 |
| 2022 July | 51 | 48 | 99 |
| 2022 June | 62 | 50 | 112 |
| 2022 May | 57 | 42 | 99 |
| 2022 April | 63 | 55 | 118 |
| 2022 March | 58 | 56 | 114 |
| 2022 February | 64 | 59 | 123 |
| 2022 January | 65 | 49 | 114 |
| 2021 December | 30 | 46 | 76 |
| 2021 November | 36 | 43 | 79 |
| 2021 October | 76 | 66 | 142 |
| 2021 September | 51 | 41 | 92 |
| 2021 August | 50 | 45 | 95 |
| 2021 July | 45 | 35 | 80 |
| 2021 June | 43 | 39 | 82 |
| 2021 May | 69 | 59 | 128 |
| 2021 April | 119 | 107 | 226 |
| 2021 March | 47 | 43 | 90 |
| 2021 February | 58 | 36 | 94 |
| 2021 January | 28 | 17 | 45 |
| 2020 December | 34 | 33 | 67 |
| 2020 November | 40 | 29 | 69 |
| 2020 October | 47 | 19 | 66 |
| 2020 September | 53 | 39 | 92 |
| 2020 August | 24 | 24 | 48 |
| 2020 July | 23 | 25 | 48 |
| 2020 June | 40 | 38 | 78 |
| 2020 May | 39 | 16 | 55 |
| 2020 April | 28 | 17 | 45 |
| 2020 March | 15 | 9 | 24 |
| 2020 February | 2 | 0 | 2 |
| 2020 January | 16 | 0 | 16 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 2 | 0 | 2 |
| 2019 March | 2 | 0 | 2 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 5 | 1 | 6 |
| 2018 April | 89 | 13 | 102 |
| 2018 March | 96 | 17 | 113 |
| 2018 February | 47 | 4 | 51 |
| 2018 January | 61 | 5 | 66 |
| 2017 December | 48 | 7 | 55 |
| 2017 November | 44 | 6 | 50 |
| 2017 October | 36 | 7 | 43 |
| 2017 September | 31 | 6 | 37 |
| 2017 August | 28 | 17 | 45 |
| 2017 July | 36 | 8 | 44 |
| 2017 June | 64 | 8 | 72 |
| 2017 May | 57 | 9 | 66 |
| 2017 April | 53 | 8 | 61 |
| 2017 March | 40 | 15 | 55 |
| 2017 February | 88 | 4 | 92 |
| 2017 January | 45 | 7 | 52 |
| 2016 December | 85 | 15 | 100 |
| 2016 November | 87 | 8 | 95 |
| 2016 October | 142 | 14 | 156 |
| 2016 September | 189 | 4 | 193 |
| 2016 August | 106 | 5 | 111 |
| 2016 July | 51 | 9 | 60 |
| 2016 June | 0 | 9 | 9 |
| 2016 May | 0 | 4 | 4 |
| 2016 April | 1 | 0 | 1 |
| 2016 March | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 1 | 0 | 1 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 3 | 16 | 19 |
| 2015 July | 36 | 7 | 43 |
| 2015 June | 42 | 5 | 47 |
| 2015 May | 49 | 8 | 57 |
| 2015 April | 45 | 6 | 51 |
| 2015 March | 44 | 6 | 50 |
| 2015 February | 56 | 9 | 65 |
| 2015 January | 51 | 15 | 66 |
| 2014 December | 51 | 8 | 59 |
| 2014 November | 54 | 11 | 65 |
| 2014 October | 64 | 10 | 74 |
| 2014 September | 43 | 8 | 51 |
| 2014 August | 62 | 14 | 76 |
| 2014 July | 71 | 13 | 84 |
| 2014 June | 90 | 8 | 98 |
| 2014 May | 88 | 15 | 103 |
| 2014 April | 65 | 11 | 76 |
| 2014 March | 74 | 9 | 83 |
| 2014 February | 60 | 11 | 71 |
| 2014 January | 80 | 9 | 89 |
| 2013 December | 46 | 4 | 50 |
| 2013 November | 45 | 7 | 52 |
| 2013 October | 68 | 9 | 77 |
| 2013 September | 65 | 9 | 74 |
| 2013 August | 73 | 14 | 87 |
| 2013 July | 53 | 10 | 63 |
| 2013 June | 58 | 14 | 72 |
| 2013 May | 71 | 10 | 81 |
| 2013 April | 86 | 10 | 96 |
| 2013 March | 58 | 10 | 68 |
| 2013 February | 48 | 12 | 60 |
| 2013 January | 62 | 7 | 69 |
| 2012 December | 54 | 7 | 61 |
| 2012 November | 38 | 8 | 46 |
| 2012 October | 19 | 7 | 26 |
| 2012 September | 25 | 3 | 28 |
| 2012 July | 4 | 0 | 4 |
| 2012 June | 27 | 0 | 27 |
| 2012 May | 38 | 0 | 38 |
| 2012 April | 24 | 0 | 24 |
| 2012 March | 7 | 0 | 7 |
| 2012 February | 5 | 0 | 5 |
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