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Tophaceous Gout Causing Atlanto-Axial Subluxation

Tophaceous Gout Causing Atlanto-Axial Subluxation

An 82-year-old African American male with a history of hypertension and polyarticular tophaceous gout presented to the emergency department (ED) with acute onset of dizziness, neck pain, and bilateral upper extremity weakness that had arisen periodically over the previous two months.

He described his neck pain as 10 o n a scale of 1 to 10, aching, non-radiating, associated with movement and worst in the morning. He attributed the pain to his sleeping posture. His symptoms had progressed in the two weeks prior to admission, culminating in numbness and weakness in the hands. He reported two episodes of syncope while turning his head, one at the dentist’s office and another during a car ride. On both occasions syncopal episode was preceded by dizziness, tingling, and numbness in his arms and accompanied by weakness, nausea, and visual disturbances. He denied postictal confusion, urine or stool incontinence, or any history of trauma. 

His home medications included 0.6 mg colchicine and 100 mg allopurinol, both daily,  for crystal-proven gout that was diagnosed 30 years ago. His most recent gout flare was 2 years ago. He reported that each flare lasts for 10 days, with joint pain and swelling.

On physical examination, the patient appeared in moderate distress due to neck pain as he was lying in bed. Vital signs on arrival to the ED were unremarkable for his advanced age. He was oriented to time, place and person.

Noteworthy laboratory findings on admission were sedimentation rate (10 mm/hr), CRP (<2.9mg/l) and uric acid level (4.9 mg/dl). RF and CCP antibody levels were within normal ranges.   

The musculoskeletal exam showed:
•    C-Spine: upper cervical and paracervical tenderness. Severe limitations of passive and active flexion (<45°), rotation (<70°), lateral bending (<40°), and extension (<45°). Full range of movement of temporomandibular joint with no tenderness or crepitus.
•    Hands:  Heberden’s and Bouchard’s nodes in the PIP and DIP bilaterally. Multiple subcutaneous nodules over the MCP, PIP, and DIP bilaterally. No discrete synovitis was noted.
•    Elbows: Multiple subcutaneous nodules with synovial thickening of the olecranon bursa bilaterally.
•    Shoulders: Deltoid muscle atrophy. Limitation of flexion and extension (<90°), external rotation and internal rotation (40°), adduction (20°), and abduction (<90°). 
•    Neurological Exam: Cranial nerves II-XII intact. Sensation to touch and pinprick wasintact. Power was 3/5 in the upper extremity proximal and distal muscles and 5/5 wasthe lower extremity. Reflexes were decreased bilaterally in the upper extremity and normal in the lower extremity. Normal gait.

The rest of the physical exam did not reveal any abnormality.

For the imaging findings, see the next page.

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