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Gout in the hip joint.

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Gout in the hip joint
Gouty arthritis in the hip joint has been mainly
described to occur in polyarticular forms (1). Very little has
been written about gouty arthritis in the hip joint, and its
diagnosis almost always has been based on a clinical picture
and history of gout in other joints (2). Herein we report a
case of monarticular gouty arthritis in an otherwise unaffected patient. To our knowledge, this is the first published
report in the English or French literature of the occurrence
of gout involving the hip alone.
The patient, a 46-year-old black man, was admitted
to the Albany Medical Center with a presumed diagnosis of
septic arthritis. He reported having moderate to severe pain
in the right hip, of 2 days duration. The earlier medical
history was significant for sickle cell trait, hypertension, and
asthma. He denied any history of arthralgia, gout, or sexually transmitted disease.
On admission the patient was afebrile, and the findings on physical examination were negative except for the
hip pain, which was accompanied by limited range of motion. The white blood cell (WBC) count was 8,500/mm3, with
60% polymorphonuclear cells. The serum uric acid level was
9.1 mg%. Magnetic resonance imaging showed no evidence
of aseptic necrosis, but there was a moderate effusion at the
right hip. Arthrocentesis of the hip showed cloudy synovial
fluid (SF) with 15,000 WBC/mm3 and 90% polymorphonuclear cells. Gram stain of the fluid did not reveal bacteria.
Polarized microscopy examination of the S F showed numerous intracellular, negatively birefringent monosodium urate
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crystals. Findings of S F culture were negative. The patient
was treated with 1 mg colchicine administered intravenously, followed by 0.6 mg orally twice a day for 3 days. The
acute gouty attack was aborted, and the patient went home
feeling well and with no symptoms.
We made a diagnosis of definite gout in this patient,
based on the American College of Rheumatology (formerly,
the American Rheumatism Association) criteria (3). A review of the English and French literature revealed that this is
the first documented case of monarticular gouty arthritis
occurring in an individual with no other involvement of gout
or arthritis. A review of 370 reported patients with gout
showed that 11 had possible or probable gouty arthritis in the
hip (2). Arthrocentesis and polarized microscopy examination were not performed. Healey et a1 reported a case of
painful gouty synovitis in the area of a prosthetic hip joint
(4); the patient had had gout affecting many other joints for
20 years. Ortman and Pack described a patient with aseptic
loosening of a total hip prosthesis secondary to tophaceous
gout ( 5 ) ; this patient also had a history of gout. Lagier
described a case of tophaceous gout diagnosed by pathologic
examination of synovial tissue of the hip joint; that report
also described radiologic changes (6). Poiraudeau and Dryll
reported the coexistence of gout and septic arthritis in the
hip joint of a patient with a long history of tophaceous gout
and multiple gouty attacks in peripheral joints (7).
The use of arthrocentesis and polarized microscopy
examination in patients who report moderate to severe pain
in the hip could result in the identification of more cases of
monarticular gout at this site. Tophus formation and severe
synovitis could lead to prosthesis loosening (5) and the
simultaneous occurrence of infectious arthritis (8). Early
recognition and treatment of gouty arthritis may prevent
these complications.
N. Parhami, MD, FACP
Helen Feng, MD
Samuel S. Stratton VA Medical Center
and Albany Medical College
Albany, N Y
I . Hadler MN, Franck WA, Bress NM, Robinson DR: Acute
polyarticular gout. Am J Med 56:715-719, 1974
2. Querol JR, Gomez JM: Manifestations de la goutte a la hanche.
Rev Rhum Ma1 Osteoartic 22:56-60, 1970
3. Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu
T-F: Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 20:895-900, 1977
4. Healey JH, Diner D, Hershon S: Painful synovitis secondary to
gout in the area of a prosthetic hip joint. J Bone Joint Surg [Am]
66:610-611, 1984
5. Ortman BL, Pack LL: Aseptic loosening of a total hip prosthesis
secondary to tophaceous gout. J Bone Joint Surg [Am] 69:109&
1099, 1987
6. Lagier R: Osteoarthritis of hip associated with microscopic gouty
tophi. Skeletal Radio1 19:69-72, 1990
7. Poiraudeau SC, Dryll GA: Coxite septique et goutteuse simultanee. Rev Rhum Ma1 Osteoartic 55:1039, 1988
8. Baer PA, Tenenbaum J, Adel F, Little H: Coexistent septic and
crystal arthritis: report of four cases and literature review. J
Rheumatol 13:604-607, 1986
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