PMC8494596_01
(a) T2 weighted axial image at L5-S1 level; (b) T2 weighted sagittal image. There is moderate diffuse circumferential disc bulging, severe right facet arthropathy, marked inflammatory changes involving the right facet joint at L5-S1, and significant edema in the posterior right paraspinous musculature near the lumbosacral junction.
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However, once the prescription had finished, he developed excruciating back pain with fevers, prompting him to go to an outside hospital, where the diagnosis of vertebral osteomyelitis was made based on an MRI of the spine showing right facet arthropathy and marked inflammatory changes at L5-S1 (Figures 1(a) and 1(b)).
(a) Tophi involving the right elbow; (b) white, chalky deposit from aspirate; (c) monosodium urate monohydrate (MSU) crystals from a gouty tophus viewed under polarized light. Strong birefringence was noted along with the needle-shaped morphology classic for MSU.
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Bilateral elbows showed the presence of swollen, bulbous white growths under the skin, likely representing tophi in the setting of uncontrolled gout (Figure 2(a)). The patient underwent bedside aspiration of the right elbow which revealed a white, chalky deposit (Figure 2(b)). The aspirate was visualized under light microscopy, confirming the presence of monosodium urate crystals (Figure 2(c)).
CT of the lumbar spine showing erosive degenerative changes of the right L5-S1 facet joint (arrow), with mild soft tissue prominence surrounding this region. Narrowing of the right L5-S1 neural foramina is also appreciated.
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CT spine showed erosive degenerative changes at L5-S1 facet joint with hypertrophy (Figure 3).
(a, b) Biopsy from right L5-S1 facet joint demonstrating large amorphous deposits (arrows) surrounded by granulomatous inflammation and foreign body giant cells, consistent with spinal gout.
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Despite antibiotic therapy, he continued to have significant pain, swelling, and fevers and subsequently underwent right L5-S1 facet joint biopsy (Figures 4(a) and 4(b)), confirming the diagnosis of spinal gout.