A 48-year-old, non-hypertensive, non diabetic man with uncontrolled gouty arthritis presented with a four-day swollen nasal mass. He was assessed to have a nasal abscess at the emergency room and was admitted for urgent management. Paranasal computed tomography (CT) scans showed a heterogeneously enhancing focus with areas of hypodensities in the nasal apex and dorsum extending into the right ala measuring 1.5 x 2.8 x 3.4 cm. with associated erosion of the cartilaginous part of the anterior nasal septum, soft tissue swelling and skin thickening in the nasal dorsum, nasal tip and right zygomatic region that was suspected to relate to an aggressive etiology. Tissue correlation was therefore recommended, and he underwent endoscopic-guided incision and drainage with biopsy and debridement of the nasal mass. The specimen submitted consisted of red to white, irregular, soft tissue fragments with an aggregate measurement of 1.5 x 1.5 x 0.5 cm. Microsections showed deposits of amorphous white to pink material with surrounding fibrosis and acute and chronic inflammatory cell infiltrates and foreign body giant cells. (Figures 1 and 2) Also seen in the background were fragments of sclerotic bone and bacterial colonies. These findings were consistent with gouty tophus with acute and chronic inflammation and bacterial colonization. The culture and sensitivity test of the nasal discharge showed growth of Enterobacter aerogenes (currently named Klebsiella aerogenes) which was identified by an automated mass spectrometry microbial identification system (VITEK® MS). Work-up also included uric acid levels which were within the reference interval at that time (6.57 mg/dL).
Gout

Periprosthetic gout flare is a rare arthritic condition after total knee arthroplasty, but the symptoms of gout may have often been mistaken as acute periprosthetic infection given their similarity. Misdiagnosis as periprosthetic infection can lead to unnecessary surgery, long-term dependence on anti-biotics, and even malfunction of the involved knee joint. Here, we report a case study of a patient with immunodeficiency condition of long-term oral glucocorticoid and diabetes mellitus, who had undergone a knee replacement 8 weeks before. The initial symptoms of fever and joint pain together with the dysfunction of her right knee with elevated inflammatory markers, such as increased serum leukocytes, erythrocyte sedimentation rate, C-reactive protein, and synovial cell counts led to a diagnosis of acute periprosthetic infection. Arthrocentesis and bacterial culture were performed preoperatively. According to the current Musculoskeletal Infection Society (MSIS) criteria for diagnosis of periprosthetic infection, the case was classified as periprosthetic infection and a prosthesis retained debridement surgery was performed. However we got negative culture results in all the pre-operative and intro-operative samples. The symptoms as well as the laboratory inflammatory markers improved shortly after the debridement surgery until the 11th day when all the similar systemic and local symptoms recurred. With a remedial crystal analysis of synovial fluid from the patient, gouty flare was found to be the cause of acute arthritis finally. Accor-dingly, after anti-gout medications were administrated, the symptoms associated with acute arthritis gra- dually subsided, and there was no recurrence during a 24-month follow-up. This article described the cli-nical manifestation, diagnosis and differential diagnosis, treatment of a case of periprosthetic gout. Although relatively rare, gout should be considered as a differential diagnosis in suspected periprosthetic infection. Current criteria for periprosthetic infection can not exclude the diagnosis of periprosthetic gout flare, it is therefore imperative that the analysis of joint aspirate for crystals be conducted to determine the correct course of treatment, or unnecessary surgical procedure may be performed in periprosthetic gout case.
Humans ; Female ; Arthroplasty, Replacement, Knee/methods* ; Gout/complications* ; Prosthesis-Related Infections/surgery* ; Symptom Flare Up ; C-Reactive Protein/analysis* ; Biomarkers/analysis*

Objective: Musculoskeletal ultrasound has gained recognition in early identification of crystal deposits in the joints and soft tissues. This study aims to validate the sonographic features of 1st metatarsophalangeal joints (MTPJs) in gout and asymptomatic hyperuricemia (AH). Methods Patients with gout (n=20) and AH (n=16) underwent a gray-scale ultrasound assessment of both 1st MTPJs on 3 positions (dorsal, medial, plantar) in longitudinal view. The static images were read by 2 blinded trained sonologists for the presence of double contour sign (DCS), erosions, and tophi.
Gout ; Validation Study

A 24-year-old male was admitted due to recurrent redness, swelling, fever and pain in the ankle, frequently accompanied by hungry feeling. Dual energy CT scans showed multiple small gouty stones in the posterior edge of the bilateral calcaneus and in the space between the bilateral metatarsophalangeal joints. The laboratory examination results indicated hyperlipidemia, high lactate lipids, and low fasting blood glucose. Histopathology of liver biopsy showed significant glycogen accumulation. The results of gene sequencing revealed the compound heterozygous mutations of the G6PC gene c.248G>A (p.Arg83His) and c.238T>A (p.Phe80Ile) in the proband. The c.248G>A mutation was from mother and the c.238T>A mutation was from father. The diagnosis of glycogen storage disease type Ⅰa was confirmed. After giving a high starch diet and limiting monosaccharide intake, as well as receiving uric acid and blood lipids lowering therapy, the condition of the patient was gradually stabilized. After a one-year follow-up, there were no acute episodes of gout and a significant improvement in hungry feeling in the patient.
Male ; Humans ; Young Adult ; Adult ; Glycogen Storage Disease Type I/genetics* ; Gout/genetics* ; Mutation ; Lipids

OBJECTIVE: To observe the diurnal difference of acute gout attacks in men, and provide reference for accurate clinical prevention and treatment. METHODS: Using a single-center, cross-sectional study design, the patients diagnosed with gout in the outpatient department of Rheumatology and Immuno-logy of PLA Joint Logistic Support Force No.980 Hospital from October 2021 to April 2022 were selected. The information about the patient's current/last acute gout attacks (less than 2 weeks from visit), date and time of attacks, joint symptoms and signs, medication use, and relevant biochemical tests on the day of visit was recorded. The diurnal time difference of acute gout attacks in male patients was analyzed, and univariate comparison and multivariate Logistic regression analyses were conducted to compare the diurnal difference of acute gout attacks with clinical characteristics and biochemical indicators. RESULTS: A total of 100 male gout patients were included, and 100 acute attacks were recorded. Diurnal distribution of acute gout attacks: morning (6:00~11:59, 18, 18%), afternoon (12:00~17:59, 11, 11%), the first half of the night (18:00~23:59, 22, 22%), the second half of the night (0:00~05:59, 49, 49%); During the day (included morning and afternoon, 29, 29%) and at night (included the first half of the night and the second half of the night, 71, 71%). The rate of acute gout attack was significantly higher at night than in the day (about 2.5 ∶1). No matter the first or recurrent gout, no matter the duration of the disease, the number of acute gout attacks had the difference of less in the day and more in the night. Serum urate (SU) level was higher in the patients with nocturnal attack than in those with daytime attack (P=0.044). Comorbidities were significantly different in the day-night ratio of the number of acute gout attack (P=0.028). Multiple Logistic regression analysis showed that SU level (OR=1.005, 95%CI: 1.001-1.009) and comorbidities (OR=3.812, 95%CI: 1.443-10.144) were the correlative factors of nocturnal acute gout attacks. CONCLUSION No matter the first or recurrent gout, no matter the duration of the disease, it has a diurnal variation characterized by multiple attacks at night, increased SU level and comorbidities are correlative factors for nocturnal acute attack of gout.
Humans ; Male ; Cross-Sectional Studies ; Gout/drug therapy* ; Arthritis, Gouty ; Gout Suppressants/therapeutic use* ; Comorbidity

Objective: Double contour sign (DCS) is considered part of the new gout classification. This study aims to determine the agreement of blinded musculoskeletal sonologists in identifying the double contour sign among asymptomatic hyperuricemic patients. Methods: Participants with asymptomatic hyperuricemia (n=65) underwent a gray-scale ultrasound assessment of both of their 1st metatarsophalangeal joints (MTPJs) done on 3 positions (dorsal, medial, plantar) in longitudinal view. The static images were read by 2 independent blinded sonologists for presence of double contour sign. Results: Among the 130 1st MTPJs, the sonologists were able to positively identify DCS on 48R and 52L, negative in 10R and 10L, with discordant readings in 7R, 3L. The overall kappa agreement was statistically significant at 0.674 (substantial agreement) and 0.842 (almost perfect agreement) on the right and left respectively, (both p<0.001). Conclusion and Recommendation There is a high proportion of positive double contour sign seen among persistently asymptomatic hyperuricemic patients. It might be prudent to perform musculoskeletal ultrasound early on to detect monosodium urate crystal deposits in similar patients. A close follow up to monitor clinical gouty arthritis maybe necessary or consider utility of urate lowering drugs in crystal dissolution in prospective studies.
Hyperuricemia ; Gout

Humans ; Bunion/complications* ; Hallux Valgus/surgery* ; Metatarsal Bones ; Metatarsophalangeal Joint ; Gout ; Synovitis

Objective: To investigate the characteristics and comprehensive treatment of infected wounds in patients with iatrogenic Cushing's syndrome. Methods: A retrospective observational study was conducted. From May 2012 to December 2021, the data of 19 patients with iatrogenic Cushing's syndrome discharged from the Department of Burns and Plastic Surgery of the First Affiliated Hospital of Guangxi Medical University were collected, including 8 males and 11 females, aged 28-71 (56±11) years, with 12 cases of infected acute wounds and 7 cases of infected chronic wounds. The lesions were located in the limbs, perianal, and sacrococcygeal regions, with original infection ranging from 9 cm×5 cm to 85 cm×45 cm. After admission, the patients were performed with multidisciplinary assisted diagnosis and treatment, and the wounds were treated with debridement and vacuum sealing drainage, according to the size, severity of infection, suture tension, and bone and tendon tissue exposure of wounds, direct suture or autologous skin and/or artificial dermis and/or autologous tissue flap transplantation was selected for wound repair. The levels of cortisol and adrenocorticotropic hormone (ACTH) of patients at 8:00, 16:00, and 24:00 within 24 h after admission were counted. After admission, the number of operations, wound repair methods, and wound and skin/flap donor site healing of patients were recorded. During follow-up, the wounds were observed for recurrent infection. Results: The cortisol levels of 16 patients at 8:00, 16:00, and 24:00 within 24 h after admission were (130±54), (80±16), and (109±39) nmol/L, respectively, and ACTH levels were (7.2±2.8), (4.1±1.8), and (6.0±3.0) pg/mL, respectively; and the other 3 patients had no such statistical results. After admission, the number of surgical operation for patients was 3.4±0.9. The following methods were used for wound repair, including direct suturing in 4 cases and autologous skin and/or artificial dermis grafting in 9 cases, of which 2 cases underwent stage Ⅱ autologous skin grafting after artificial dermis grafting in stage Ⅰ, and 6 cases had pedicled retrograde island flap+autologous skin grafting. The wound healing was observed, showing that all directly sutured wounds healed well; the wounds in 6 cases of autologous skin and/or artificial dermis grafting healed well, and the wounds in 3 cases also healed well after the secondary skin grafting; the flaps in 4 cases survived well with the wounds in 2 cases with distal perforators flap arteries circumfluence obstacle of posterior leg healed after stage Ⅱ debridement and autologous skin grafting. The healing status of skin/flap donor sites was followed showing that the donor sites of medium-thickness skin grafts in the thigh of 4 cases were well healed after transplanted with autologous split-thickness grafts from scalp; the donor sites of medium-thickness skin grafts in 3 cases did not undergo split-thickness skin grafting, of which 2 cases had poor healing but healed well after secondary skin grafting 2 weeks after surgery; the donor sites of split-thickness skin grafts in the head of 2 patients healed well; and all donor sites of flaps healed well after autologous skin grafting. During follow-up of more than half a year, 3 gout patients were hospitalized again for surgical treatment due to gout stone rupture, 4 patients were hospitalized again for surgical treatment due to infection, and no recurrent infection was found in the rest of patients. Conclusions: The infected wounds in patients with iatrogenic Cushing's syndrome have poor ability to regenerate and are prone to repeated infection. Local wound treatment together with multidisciplinary comprehensive treatment should be performed to control infection and close wounds in a timely manner, so as to maximize the benefits of patients.
Adrenocorticotropic Hormone ; China ; Cushing Syndrome/surgery* ; Female ; Gout ; Humans ; Hydrocortisone ; Iatrogenic Disease ; Male ; Skin, Artificial ; Wound Infection

OBJECTIVE: To develop and test the health education knowledge assessment questionnaire for gout and to investigate the understanding degree of health education knowledge in patients with gout. METHODS: From June 2019 to June 2019, 150 cases of gout patients were enrolled.According to the literature review and the healthy education requirements of gout patients, the framework of education knowledge system was preliminarily formed.The pre-test questionnaire was obtained through two rounds of he Delphi technique.A survey of 150 patients with gout was carried out.The analysis and selection of the questionnaire were based on the coefficient of variation, the analysis of determination value, the correlation coefficient of the items and the total scores, and the exploratory factor analysis.In this study, we evaluated the reliability of internal consistency, semi-reliability.Validity test mainly included content validity and construct validity.In addition, a total of 150 patients with gout in our hospital and outpatient gout were selected to investigate the understanding degree of health education knowledge from June 2019 to December 2019. RESULTS: The significance of the first level index of the questionnaire was 3.83-5.00, the secondary index was 3.00-4.83, and the variation coefficient of each item was 0.31-1.23, and the critical ratio(CR) value of each item in this questionnaire was 3.168-8.333.The Pearson correlation coefficient of each item and the total score of this study was 0.319-0.544.After exploratory factor analysis, some topics were deleted in four dimensions, and there were 16 entries in the final questionnaire.Cronbach' s α coefficient of this questionnaire was 0.715, split-half reliability Spearman-Brown coefficient was 0.785, and retest reliability coefficient was 0.729. The correlation coefficient between each factor of this questionnaire and the total questionnaire was 0.300-0.701, and the correlation coefficient between each item of the questionnaire and each factor was 0.402-0.732, all P < 0.05. The results were statistically significant. By questionnaire investigation, the total score of questionnaire was (6.85±3.22), the score of disease-related knowledge was (2.03±1.24), the score of dietary guidance was (1.53± 1.06), the score of exercise guidance was (2.19±1.24), the score of medication guide was (1.24±1.22). CONCLUSION The Health Education Knowledge Assessment Questionnaire For Gout has a good reliability and validity for measuring related content, the compilation process is scientific and the content is comprehensive, which can be further applied in clinic.The understanding degree of health education knowledge is low in Chinese patients with gout, and knowledge of gout medicine is lacking especially.
Factor Analysis, Statistical ; Gout/diagnosis* ; Health Education ; Humans ; Psychometrics/methods* ; Reproducibility of Results ; Surveys and Questionnaires

OBJECTIVE: To evaluate the relationship between 24 h urinary ion content and kidney stones, and to explore the diagnostic values of kidney stone in primary gout patients. METHODS: Patients diagnosed with primary gout had ultrasound scanning of both feet and kidneys in Peking University First Hospital from Jan. 2020 to May 2021. Their clinical characteristics were compared between the positive and negative kidney stone groups, and the relationship between kidney stone and urinary ion composition were analyzed. Risk factors of kidney stone were analyzed. The explored diagnostic values were evaluated for urinary oxalate and citrate according with uric acid kidney stones by dual-energy computed tomography (DECT). RESULTS: Among the 100 gouty patients, 80 patients had uric acid crystal deposition in lower joints of extremity by ultrasonography, 61 patients had kidney stone, and 34 had kidney uric acid stones by DECT. All the multiple kidney stones were proved as uric acid kidney stones by DECT. Compared with patients without kidney stone group proved by ultrasonography, patients with kidney stone had longer gouty duration [(48.7±26.6) months vs. (84.0±30.6) months, P=0.01], higher 24 h urinary oxalate [(20.1±9.6) mg vs. (28.6±20.7) mg, P=0.001] and lower 24 h urinary citrate [(506.3±315.4) mg vs. (355.7±219.6) mg, P=0.001]. Compared with the patients without kidney stone by DECT, the patients with uric acid kidney stone also had longer disease duration [(49.1±28.4) months vs. (108.3±72.2) months, P=0.001], higher 24 h urinary oxalate [(23.6±16.9) mg vs. (28.5±18.8) mg, P < 0.05], lower 24 h urinary citrate [(556.0±316.3) mg vs. (391.7±261.2) mg, P < 0.05], higher serum uric acid [(466.2±134.5) μmol/L vs. (517.2±18.1) μmol/L, P < 0.05] and higher 24 h urinary uric acid [(1 518.1±893.4) mg vs. (1 684.2±812.1) mg, P < 0.05]. Logistic regression analysis showed long gout disease duration (OR=1.229, 95%CI: 1.062-1.522, P < 0.05), high serum uric acid level (OR=1.137, 95%CI: 1.001-1.213, P=0.01), low 24 h urinary citrate (OR=0.821, 95%CI: 0.659-0.952, P=0.01) were all risk factors of kidney stones by ultrasonography. Also, long gout disease duration (OR=1.201, 95%CI: 1.101-1.437, P=0.005), high serum creatine uric level (OR=1.145, 95%CI: 1.001-1.182, P=0.04), low 24 h urinary citrate (OR=0.837, 95%CI: 0.739-0.931, P=0.02) were all risk factors of kidney uric acid stones by DECT. CONCLUSION Long disease duration and low 24 h urinary citrate were risk factors for kidney stones.
Humans ; Urinary Calculi ; Uric Acid/analysis* ; Citric Acid ; Kidney Calculi/diagnostic imaging* ; Gout/diagnostic imaging* ; Citrates ; Oxalates