[Klinisch beeld] Jichtige tophus in de quadriceps-pees: sluit kwaadaardigheid uit

[Klinisch beeld] Jichtige tophus in de quadriceps-pees: sluit kwaadaardigheid uit

december 27, 2019 0 Door admin

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A 69-year-old man attended our outpatient department with pain and discomfort just above both his knees. He said the problem had been troubling him for 4 months. On examination, we found swelling of the soft tissue at the end of the quadriceps tendon of his right leg (

figure

); the patient had a full range of movement of his knee with no weakness. The x-ray showed an ill-defined erosion of the proximal patella with calcification of the distal quadriceps tendon (

figure

). MRI showed that the mass was invading the proximal patella, with uptake of contrast agent at the margins extending into the quadriceps tendon without penetrating the knee joint capsule in sagittal reconstructions (

figure

). Our differential diagnoses at this stage for the lesion included a giant cell tumour of the tendon sheath and a soft tissue sarcoma. We then did an MRI-guided biopsy. Histological analysis showed confluent granulomas with oligocellular, amorphous eosinophilic masses and a perifocal chronic inflammatory reaction with foreign-body giant cell response, which was indicative of a gouty tophus (

figure

). Monosodium urate crystals were not detectable by polarised light microscopy because they were dissolved by the formalin used to fix the histological sections. Serum urate concentration was 9·3 mg/dL (normal

Figure thumbnail gr1

Figure Gouty tophus in the quadriceps tendon

Swelling (pink arrowhead) at the end of the quadriceps tendon (A). The x-ray shows an ill-defined erosion (pink arrowhead) of the proximal patella with calcification of the distal quadriceps tendon (B). MRI shows the mass (pink arrowhead) invading the proximal patella, with uptake of contrast agent at the margins extending into the quadriceps tendon (C). Histology shows confluent granulomas with oligocellular, amorphous eosinophilic masses, which represent monosodium urate crystal deposition (green arrowheads) and a perifocal chronic inflammatory reaction with multinucleated foreign-body giant cell response (blue arrowheads; haematoxylin and eosin stain; original magnification × 200; D).

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Article Info

Publication History

Published: 14 December 2019

Identification

DOI: https://doi.org/10.1016/S0140-6736(19)32950-2

Copyright

© 2019 Elsevier Ltd. All rights reserved.

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