SEVERE DISSEMINATED CUTANEOUS GOUT -CASE REPORT-

1
SEVERE DISSEMINATED CUTANEOUS GOUT-CASE REPORT-
Irina Tudose1, Olguta Anca Orzan2, Diana
Petrache2, Prof. Dr. Calin Giurcaneanu2
1 Pathology Department, Elias University
Emergency Hospital, Bucharest 2 Dermatology
Department, Elias University Emergency Hospital,
Bucharest

• We present the case of a 53-year-old obese
  caucasian male with a history of severe
  hyperuricemia and acute gouty arthritis frequent
  hunter and consumer of venison

Chief complaints disseminated yellow skin
nodules dating for about five years with an
accelerated development of the lesions during the
last year.
Histopathological examination (2010) chronic
granulomatous inflammatory process, endogenous
foreign body, most likely dermal calcinosis
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Past medical history (PMH) Gouty arthritis
(1996) inconsistently treated Focal segmental
glomerulosclerosis (renal biopsy, 2003) Chronic
renal failure Moderate chronic anemia Essential
hypertension (2004) Medication Verapamil,
Furosemide Family history (FH) not significant.

• Grade III obesity (BMI 43 kg/m2)
• Joint swelling (right knee joint and bilateral
  hand interphalangeal joints)
• No lung rales, BP 130/80 mm Hg, AV 80/min
• no bowel obstruction, occasionally rectorhagia

• inflammatory syndrome (ESR 96 mm/h, Fb 475
  mg/dl)
• anemia (Hb 10 g/dl, Ht 32.2)
• nitrogen retention (creatinine 1.83 mg/dl)
• uric acid 11.45 mg/dl
• mild hyperkalemia
• proteinuria (1.2 g/24 h)

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Clinical examination

• Multiple disseminated nodules, 1-15 mm diameter,
  some of them ulcerated and draining a white
  chalky material

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Histopathological examination

• Usual and special stains
• Haematoxilin-eosin
• Periodic acid Schiff (PAS)
• Gömöri stain for reticulin fibers
• Von Kossa stain for calcium deposits
• Red of Congo for amiloid
• Elastic Von Gieson for elastic fibers
• Polarized light examination

Histopathological description Two pieces of skin
showing dermal granulomatous chronic inflammation
with numerous multinucleated giant cells of
"foreign body" and foamy macrophages located
around focal areas of extensive deposition of
amorphous material, acellular, pale-basophilic
with focal areas of central suppurative necrosis.
After using special stains, it was established
that histopathological appearance is compatible
with the diagnosis of gout.
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Large areas of amorphous acellular,
pale-basophilic material deposition surrounded by
chronic granulomatous inflammation
HEx40
HEx40
HEx200
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Gx400
vGx200
Van Gieson stain for elastic fiber, preserved
in the periphery areas of amorphous material
deposition
Gömöri stain for reticulin fibers
RCx400
Von K x200
Von Kossa Stain - for the evidence of calcium
salts, absent in this case
Red of Congo for amiloid, absent in this
case
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Calcinosis cutis universalis deposits of calcium
phosphate crystals in the tissues
Differential diagnosis
Rheumatoid nodules areas of fibrinoid necrosis
boardof chronic granulomatous inflammation

Von Kossa
PAS
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• Polarized light examination
• A few monosodium urate crystals were found
  because of the formalin 10 preservation of the
  sent specimens

Particularities of the case

• Rare disease
• Davis L. Disseminated cutaneous gout A
  rapid onset of disease. J Am Acad Dermatol 2011
  64 (2 Supp 1) AB113
• Severity form (uric acid 7.87 mg/dl ? 16.1
  mg/dl) and the long term evolution (15 years)
• Focal segmental glomerulosclerosis associated