History and physical findings: A 67-years-old man suffered from relapsing moderate fever and back pain after arthroscopy of the knee under peridural anaesthesia. Antibiotics given for suspected iatrogenic infection was started, but was without improvement. After 4 months under several antibiotic regimes his condition rapidly deteriorated with high fever, excruciating lumbar back pain associated with elevated ESR/WBC (ESR = erythrocyte sedimentation rate, WBC = white blood cell count) along with arthritis of the shoulders, wrists, knees and ankles. Physical findings comprised swelling and restricted movement of the affected joints as well as pain related stiffness and immobility of the spine, but no neurological abnormalities.
Clinical investigations: An magnetic resonance imaging (MRI) of the lumbar spine revealed the uncommon finding of multilevel facet joint arthritis at lumbar L2/3 and L4/5, accompanied by cystic erosions of the lamina and widespread dorsal soft tissue edema. Serum uric acid was 11 mg/dl. Uric acid was found in the synovial fluid of the knees.
Diagnosis, treatment and follow up: The fever, spinal symptoms as well as imaging findings improved together with the peripheral arthritis when treatment with colchicine and steroids was started, establishing the diagnosis of spinal gout. In the following year, no further or back pain or fever occurred. Despite continued allopurinol therapy the gouty arthritis of the peripheral joints re-occurred.
Conclusion: Despite its rarity, spinal gout should be considered in the differential diagnosis of intractable back pain and fever especially when imaging studies reveal posterior element involvement.
Georg Thieme Verlag KG Stuttgart.New York.