Cervical spinal gout

An 85-year-old man was admitted to hospital with a 5-day history of fever and neck pain. He had a 12-year history of chronic kidney disease and gouty arthritis; however, the patient did not take urate lowering drugs. On admission to hospital, physical examination revealed neck pain and stiffness. He had a blood pressure of 140/102 mm Hg, pulse rate of 95 per min, respiration rate of 18 breaths per min, and body temperature of 38°C. Laboratory results revealed a white blood cell count of 11 200 cells per mm3 (reference 4 000–10 000) and C-reactive protein level of 12·26 mg/dL (reference 0·0–0·3). MRI findings suggested cervical osteomyelitis and meningitis (figure A). Cervical spine CT revealed curvilinear calcifications of the transverse ligament of the atlas (figure B). After assessing blood cultures, ceftriaxone (2 g every 12 h) and vancomycin (1750 mg loading, followed by 750 mg every 48 h) were administered intravenously as empirical antibiotic treatments. On the second day of admission, cerebrospinal fluid (CSF) analysis did not reveal meningitis (white blood cell count 8 cells per μL, glucose concentration 79 mg/dL, and protein concentration 168 mg/dL), and CSF culture and molecular tests were negative for bacteria and mycobacteria. The patient was diagnosed with crowned dens syndrome and administered 20 mg prednisolone, and his symptoms dramatically improved. However, CSF examination under polarising microscopy revealed monosodium urate crystals (figure C). Dual-energy CT confirmed the calcifications to be monosodium urate crystals (figure D). The patient's uric acid concentration was 10·4 mg/dL (reference 0–7·0) and subcutaneous tophi were not apparent on physical examination 9 days after hospital admission. Crowned dens syndrome is a rare finding in calcium pyrophosphate deposition disease and could be clinically similar to meningitis, so it should be suspected when the evidence for infection is unclear. Our patient had a history of gout, and monosodium urate crystals were confirmed by CSF analysis and dual-energy CT, suggesting that the symptoms were caused by gout flare in the cervical spine. Thus, physicians should consider that intrathecal monosodium urate crystal formation can cause meningitis-like symptoms in patients with gout history.