Concomittan Hyperuricemia and Abcess Mid Thoracic Region: The Use of Dual Energy CT Scan

Dual energy scan was performed to differentiate any collection associated with calsium. Case report. This 23 year old man showed severe hyperuricemia and mid thoracic pain and MRI showed collection over posterior epidural thecal sac over T3 until T9. Dual energy CT scan was performed to assess uric acid crystal over thoracic region. The CT result was negative. He was treated over intravenous antibiotic and pain medication. His pain improved progressively and laboratory results showed towards normal value and he was discharged on day twelveth. Conclusion. This case report showed the comprehensive diagnostic tool to yield out the aetiology of thoracal epidural collection, despite negative result. Keywords: Hyperuricemia, abcess, mid thoracic, dual energy, CT scan

Erythrodermic Psoriasis Causing Uric Acid Crystal Nephropathy

Background. Erythrodermic psoriasis is a rare and severe variant of psoriasis. It is characterized by widespread skin erythema, scaling, pustules, or exfoliation of more than 75% of the body’s surface area. This condition has life-threatening complications to include hemodynamic, metabolic, immunologic, and thermoregulatory disturbances. One metabolic complication, hyperuricemia, occurs from rapid keratinocyte differentiation and infiltration of inflammatory cells into psoriatic lesions. Although renal injury caused by shunting of blood to the skin has been reported, there are no reports of erythrodermic psoriasis causing crystal-induced nephropathy. We present a case of erythrodermic psoriasis and hyperuricemia complicated by uric acid crystal nephropathy. Case Presentation. A 57-year-old male with long-standing psoriatic arthritis presented with diffuse scaling of his skin. He was being treated with adalimumab, leflunomide, and topical clobetasol, but had recently stopped taking his medications. Physical exam revealed yellow scaling covering his entire body with underlying erythema and tenderness without mucosal involvement. Labs were notable for a creatinine of 3.3 mg/dL, with no prior history of renal disease, and uric acid of 12.7 mg/dL. He was admitted to the intensive care unit given >80% of body surface area involvement and acute renal failure. Despite aggressive fluid resuscitation, renal function did not improve, and creatinine peaked at 4.61 mg/dL. Urine microscopy showed diffuse polymorphic uric acid crystals, consistent with uric acid crystal-induced nephropathy. He was started on rasburicase, urinary alkalinization, and fluids. His renal function improved dramatically; urine output, uric acid, and electrolytes normalized. He was discharged on topical clobetasol and leflunomide and started on secukinumab with little to no skin involvement. Conclusion. This case presents the rare complication of crystal-induced nephropathy in a patient with erythrodermic psoriasis. Uric acid crystal nephropathy is well described in diseases with rapid cell turnover such as tumor lysis syndrome. It is thought that rapid keratinocyte differentiation and inflammatory infiltration of psoriatic lesions produced life-threatening electrolyte abnormalities similar to tumor lysis syndrome. Early recognition of this rare complication is critical, and aggressive fluid resuscitation, urine alkalinization, and uric acid lowering agents should be administered immediately.

Gout - asymptomatic hyperuricemia with/without asymptomatic monosodium urate crystal deposition: To be treated or not?

Elevation of serum uric acid level without clinically visible arthritis (known as asymptomatic hyperuricemia) is not traditionally considered to be gout disease, but only a possible cause of it, even though it may be accompanied by tissue uric acid crystal deposition. On the other hand, gout is traditionally recognized as recurrent, overt arthritis, visible only after a long period of time due to uric acid accumulation in joints. Advanced imaging techniques have substantially changed the perception of this problem, identifying gout as a low-grade chronic inflammatory disease from the very beginning, visible only by phases of acute arthritis attacks. According to ultrasonography, uric acid crystal hyperechoic aggregates (tophi) are seen not only in the symptomatic gout disease phase, but also in the preceding ? asymptomatic (latent) ? gout phase. New perception of the problem was approved by the recently described NETs (neutrophil extracellular traps) phenomenon. Also, hyperuricemia has recently been identified as a systemic disorder, responsible not only for the apparent gout arthritis, but also for the renal and cardiovascular disease occurrence and progression. Positive effect of urate-lowering therapy (xanthine oxidase inhibitors and uricosurics) on hypertension and chronic kidney disease indicates a possibility of its utility in asymptomatic hyperuricemia and asymptomatic gout therapy, apart from the use in clinically manifested gout treatment and for certain conditions, such as tumor lysis syndrome.