International Journal of Research in Medical Sciences

Patil BR et al. Int J Res Med Sci. 2016 Apr;4(4):1302-1303

www.msjonline.org

pISSN 2320-6071 | eISSN 2320-6012

Case Report

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20160832

A large multilobulated ankle swelling: rare presentation of gout

Bhushan R. Patil*, Chandrashekhar Wahegaonkar, Nikhil Agarkhedkar

Department of Plastic Surgery, Dr D Y Patil Medical College, Pimpri, Pune, Maharashtra, India

Received: 14 February 2016

Accepted: 08 March 2016

*Correspondence:

Dr. Bhushan R. Patil,

E-mail: drbhushanrpatil@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

We are presenting a case study of a male patient presented to our outpatient department with large lobulated hard swelling in subcutaneous plane of left ankle. We found large whitish soft tissue masses. We did chemical analysis of same and it showed presence of uric acid crystals. This is a very rare presentation of gout. Upto the best of our knowledge only one such lesion has been reported from Turkey. So we wish to report this rare presentation of Gout.

Keywords: Ankle swelling, Gout, Rare gout lesion, Uric acid crystals

INTRODUCTION

Gout is a medical condition usually characterized by recurrent attacks of acute inflammatory arthritis of small joints.1 The first metatarsophalangeal joint is the most commonly affected joint (50%). The deposition of uric acid crystals is clinically presented with acute attacks of affected joint arthritis and tophaceous joint swellings.

CASE REPORT

A 60 year old male patient vegetarian by diet presented to us with swelling over left ankle for 2 years. Swelling was smaller in size to begin with but increased to present size (6x6 cm) over 2 years (Figure 1). There was no history of trauma, infection or any operative procedure done at local part involved. Patient denied any episodes of recurrent small joint arthritic attacks in past. There was no history of recurrent pain at ankle of severe intensity. Patient was non-diabetic, non-hypertensive. On investigations uric acid level was raised (9 mg/dl). On X-ray there was no bony involvement. After discussing with patient, we planned for resection of swelling. We performed skin sparing resection of swelling and removal of entire soft tissue mass with primary closure of wound (Figure 2). Soft tissue masses were white, rough surfaced, firm masses giving specimen its multilobulated appearance (Figure 3). We sent them for chemical analysis and it showed presence of refractile bipolar needle like crystals suggestive of uric acid (Figure 4).2 Patient on follow up showed good healing of wound and no recurrence.

Figure 1: Pre-operative photograph of ankle swelling.
Figure 1: Pre-operative photograph of ankle swelling.
Figure 2: Post-operative photograph after excision and primary closure.
Figure 2: Post-operative photograph after excision and primary closure.
Figure 3: Specimen
Figure 3: Specimen
Figure 4: Chemical report.
Figure 4: Chemical report.

DISCUSSION

Gout is a metabolic disorder involving protein metabolism.3 Patients commonly present with severe recurrent attacks of small joint arthritis. It is also known as ‘podogra’.4 The propensity of gout for the foot was recognised by the ancient Greeks who referred to it as podagra, literally "foot-grabber".5 Hippocrates described it as ‘unwalkable disease’ rightly denoting the severity. Treatment mainly involves anti-inflammatory agents, immune modulators and drugs inhibiting enzyme xanthine oxidase. Incidence of gout in elderly patients is rising due to renal diseases and dietary factors. But gout presenting as ankle mass requiring surgical excision is rare and not much documented in literature (Only one case report at Turkey).6 Hence we have decided to report the case.

CONCLUSION

Gout can have varied presentations and one must consider gout as one of the differential diagnosis in soft tissue mass at large joints.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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