Type of publication:
Conference abstract

Author(s):
*Goel N.; *Amarasena R.

Citation:
International Journal of Rheumatic Diseases; Sep 2021; vol. 24 ; p. 177

Abstract:
A 42 year old Caucasian gentleman presents with acute left knee swelling, developed over 3 days without preceding trauma. He was referred to Trauma and Orthopaedics who aspirated the knee, finding no organisms or crystals. Following readmission 4 days later with the same complaint, re-aspiration again showed no crystals or organisms. MRI of the left knee showed femoral condyle oedema, initially suggesting Osteomyelitis, but on re-discussion with the radiologist seemed unlikely. The patient was started on Indomethacin and referred to Rheumatology. Despite having some symptomatic relief, he developed progressive swelling in the left calf, ankle and foot. Blood tests confirmed raised D-Dimer and rising CRP: 142 (ref range 0-5). Ultrasound Doppler of the left leg revealed no evidence of DVT, but did show pockets of fluid in the lower thigh, which were noted on previous MRI. X-rays of the knee and ankle did not show any pathological changes. Following Rheumatology review, it was postulated that he could have myofasciitis or infection. RF and CCP were found to be negative with normal complement levels and CK. Further MRI of the left leg showed progressive persistent oedema in the lateral femur. He was commenced on Intravenous flucloxacillin and diclofenac for suspected infection. Following 10 weeks of investigations and management, an MDT discussion opted for Dual Energy CT scan to look for evidence of gout. The Dual Energy CT scan showed extensive gout crystal deposition in the left knee, as well as affecting the popliteus tendon. He was commenced on Prednisolone, counselled on lifestyle factors and later started on Allopurinol that was up-titrated with bridging Colchicine, with excellent response. This case highlights the advances in Dual Energy CT scanning in helping to diagnose gout in those patients with atypical presentation and negative results on needle aspiration.

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