910 LETTERS Tophaceous neck mass presenting as a thyroglossal duct cyst To the Editor: Patients with tophaceous gout frequently have deposits within the articular cartilage, synovium. tendons and tendon sheaths, bursae, pinnae, and soft tissues on the extensor surfaces of the forearms ( I ) . Rarely reported sites of tophus include the larynx (2), nasal cartilage (3), myocardium and pericardium ( I ) , cardiac valves (41, and the spinal cord (5.6). We report a case of tophaceous deposits in the soft tissues of the neck, mimicking a thyroglossal duct cyst. The patient, a 63-year-old man with a 20-year history of alcohol abuse and a 10-year history of tophaceous gout, was admitted to the Medical Service of the Brooklyn Veterans Administration Medical Center for evaluation of an anterior neck mass. The patient first noted the slowly enlarging mass approximately 4 weeks prior to admission. The medical history was significant for a subtotal gastrectomy, which was performed 20 years previously for a bleeding ulcer. The patient had had arthralgias for many years, relieved by occasional acetaminophen use. He had never been given uric acid-lowering drugs. Physical examination of the patient revealed topha- Figure 2. Gross appearance of the resected neck mass after excision. Note the nodular and diffuse chalky white deposits on the inner surface of the cystic mass. Figure 1 . Gross appearance of the neck mass prior lo surgery ceous deposits over both elbows and in several interphalangeal joints of the hands and feet. A midline bilobed anterior neck mass was noted. with each lobe measuring 2.5 cm in diameter. The mass moved with deglutition. was nontender, fluctuant, and nontransilluminating. Clinically, the patient appeared to have a thyroglossal duct cyst (Figure I ) . Laboratory findings included a serum uric acid level of 9.9 mg/dl, with a 24-hour uric acid excretion of 0.65 gm. Thyroid function tests revealed a T, resin uptake of 39.7%, a T, level of 5.4 &dl. a T, level of <50 ng/ml, and a thyroid-stimulating hormone level of 0.8 pU/ml. Antimicrosomal and antithyroglobulin antibodies were negative. Ultrasound examination of the mass demonstrated 2 lobes; the right lobe was solid with nodular components, and the left lobe was hypoechoic and cystic. Computed axial tomography revealed a 2-lobed structure in front of a normal thyroid gland. Radioiodide scan of the thyroid gland showed normal size, shape, and uptake. Needle aspiratiqn of the right lobe of the mass was performed, and 2 ml of chalky white, semisolid material was removed. Innumerable needle-shaped crystals with negative birefringence were seen under a polarizing microscope, using a first-order red compensator. The patient underwent surgical excision of the mass, performed primarily for cosmetic reasons. The surgeon believed it was a thyroglossal duct cyst, based on its gross appearance and location. There was no communication with any underlying deep structure of the neck. Following excision, further examination of the mass revealed it to be thick-walled and cystic, and filled with the same chalky white material that was aspirated preoperatively (Figure 2). Microscopic examination showed a cystic structure devoid Arthritis and Rheumatism, Vol. 33. No. 6 (June 1990) 91 1 LETTERS of an epithelial lining, with a wall composed of fibrous tissue that contained masses of amorphous eosinophilic material surrounded by foreign-body giant cells. In the alcohol-fixed sections, clusters of birefringent needle-shaped crystals, characteristic of monosodium urate, were seen within the wall. There was no evidence of thyroglossal duct tissue in the specimen. This patient presented with a cystic mass that was shown to be a large tophus within the soft tissues of the neck. Preoperative evaluation established that the tophus was anterior to and anatomically distinct from a normally functioning thyroid gland. The tophus seems to have developed within previously normal soft tissues. Earlier reports have noted tophaceous deposits within various structures of the neck, including the arytenoid cartilage, true vocal cords, hyoid bone, and the thyroid cartilage (2). However, in the present case. no relationship with any definable neck structure was noted at the time of surgery. This represents the first reported case of a tophus mimicking a thyroglossal duct cyst. Andre Landau, MD Doyle J. Reese, MD State University of New York Health Science Center at Brooklyn David R. Blumenthal, MD Nena W. Chin, MD Veterans Administration Medical Center Brooklyn, N Y 1. Krane SM: Crystal induced disease, ScientLfic American Medi- 2. 3. 4. 5. 6. cine. Edited by E Rubenstein. DD Federman. New York. Scientific American, 1986 Stark TW, Hirokawa RH: Gout and its manifestations in the head and neck. Otolaryngol Clin North Am 15:659-664. 1982 Rask MR. Kopf EH: Nasal gouty tophus (letter). JAMA 240:636. I987 Dennstedt FE. Weilbaecher DG:Tophaceous mitral valve. Am J Surg Path01 6:79-81, 1982 Sequeira W, Bouffard A, Salgia K, Skosey J: Quadraparesis in tophaceous gout. Arthritis Rheum 24:1428-1430, 1981 Wald SL, McLennan JE. Carroll RM. Segal H: Extradural spinal involvement by gout. J Neurosurg 50:236239. 1979 F i v 1. Radiograph o f t h e patient*s left elbow. showing irregular of the capitellurn, flattening of the capitellar articular surface. an intraarticular loose body, and hypeitrophic response of the radial head. Comment on the article by Daniel To the Editor: We read with interest the report on Panner's disease, by Daniel (Daniel WW: Panner's disease. Arthritis Rheum 32:341-342. 1989). We agree that the disorder frequently continues undiagnosed because of the mild symptoms. We recently treated a patient with Panner's disease and report our findings herein. The patient, a 19-year-old man, presented in July 1989 with a painful left elbow. For 3 years prior to examination, he had experienced pain in the left elbow, with progressive intensity, especially when playing tennis or handball, and for several weeks prior to examination, he had noted crackling on movement of his left elbow. There was no clear history of trauma. The patient was ambidextrous, but between the ages of 11 and 15, he had played tennis left-handed. On physical examination, there was minor restriction of the range of motion of the left elbow, with crackling on motion. Radiographs of the elbow showed irregular mineralization of the capitellurn, with flattening of the capitellar Figure 2. Tomograph of the patient's left elbow in flexion. showing flattening of the capiteuar articular surface and an intraarticular loose body.