Tophaceous gout in thoracic spine mimicking meningioma: A case report and literature review

Abstract

Background: Gout is a common metabolic disorder of purine metabolism, causing arthritis in the distal joints of the appendicular skeleton. Spine involvement is rare, and very few cases of spinal gout have been reported. The authors present a rare case of axial gout with tophaceous deposits in the thoracic spinal canal resulting in cord compression and mimicking a meningioma.

Case description: A 33-year-old male presented with chronic mid back pain and a progressive paraparesis. The presumed diagnosis was meningioma based on MR imaging with/without contrast that showed a posterolateral, right-sided, and T10-T11 intradural extramedullary lesion. Notable, was hyperuricemia found on hematological studies. The patient underwent a decompressive laminectomy (T9-T11) for excision of the lesion, intraoperatively, an intraspinal, chalky, white mass firmly adherent to and compressing the dural sac was removed. The histopathology confirmed the diagnosis of a gouty tophus. Postoperatively, the patient's pain resolved, and he regained the ability to walk.

Conclusion: A gouty tophus should be included among the differential diagnostic considerations when patients with known hyperuricemia present with back pain, and paraparesis attributed to an MR documented compressive spinal lesion.

Keywords: Axial gout; Meningioma; Spinal gout; Thoracic spinal gout; Tophaceous gout.

Figure 1:

Magnetic resonance imaging of thoracic spines. (a) Sagittal plane T1-weighted section. (b) T2-weighted section. (c) Contrast-enhanced T1-weighted section. (d) Axial plane T1-weighted section. (e) T2-weighted section. (f) Contrast-enhanced T1-weighted section. The images show an oval extramedullary intradural mass lesion (3.0 × 1.6 cm in size) at T10-11 lying to the right posterolateral aspect of the spinal cord. The lesion shows heterogeneous low signal intensity on T2W images and iso- to low signal intensity on T1W images with moderate heterogeneous enhancement.

Figure 2:

Intraoperative photographs. Intraspinal lesion (a) and Chalky white material firmly adherent to the dura mater (b) (see arrows). The dural sac after complete excision of the gout tophus (c).

Figure 3:

Microphotograph of histopathology showing acellular eosinophilia gouty tophi (G) surrounded by an inflammatory reaction and multinucleated giant cells (arrow) (H&E × 40).