Recognition of gout in rheumatoid arthritis: A case report

Abstract

Rationale: Rheumatoid arthritis (RA) and gout are common rheumatic diseases. However, their coexistance has been rarely reported. Here in, we describe a case of a middle aged Chinese woman having RA complicated with atypical gout on both the knee joints.

Patient concerns: A 44-year-old Chinese woman complained of swelling and tenderness of multiple joints since 10 months. She had a positive rheumatoid factor and high titers of anti-CCP antibody. She was diagnosed with RA, and commenced on methotrexate, leflunomide, and methylprednisolone. Her symptoms of pain and swelling over interphalangeal and wrists joints subsided except the knee joints. She was started with treat to target treatment (TTT) for RA and rest of her medications was adjusted accordingly. Surprisingly, her symptoms did not improve ever after the addition of a biologic agent, tumor necrosis factor (TNF)-α receptor antagonist.

Diagnosis: Presence of urate crystals in the synovium was viewed under polarization microscope which was extracted from one of the knee joint. Hence, we established the diagnosis of RA complicated with gout.

Interventions: We commenced her on TNF-α receptor antagonist, colchicines, and febuxostat.

Outcomes: Her symptoms of pain and swelling improved significantly on both the knees and no longer recurred.

Lessons: Coexistence of RA and gout has been rarely reported as it is not frequently seen in clinical practice. Hence, when patients with RA with oligoarthritis repeatedly do not respond to TTT, a standard antirheumatism treatment, the possibility of RA complicating with gout should be rule out.

Figure 1

X-ray imaging of both hands. Joint space narrowing of the bilateral wrist and the interphalangeal joints.

Figure 2

An ultrasonography of right knee joint. A “double track sign” of the articular cartilages (TIF).

Figure 3

Positive briefringence needle-like crytals of extracted knee joint fluid.