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Tophaceous neck mass presenting as a thyroglossal duct cyst.

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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.
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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.
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mass, thyroglossal, neck, presenting, tophaceous, cysts, duct
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