Background Gout is a clinical syndrome associated from the deposition of monosodium urate crystals. Typically, the first attack of acute gout occurs after 15 to 20 years of asymptomatic hyperuricemia. Attacks are typically monoarticular and have a predilection for the lower extremity. Joints commonly affected are the first metatarsophalangeal joint, ankle, and knee. This is a case report of an unusual presentation of acute gouty arthritis that involved multiple joints on initial presentation, including migratory arthritis, joint swelling, neck stiffness, and high-grade fever. The differential diagnosis in this patient's presentation was diverse and included meningitis, Lyme disease, septic arthritis, and West Nile virus encephalitis.
Case Report A 60-year-old male with a past medical history of hypertension, asthma, and multiple sclerosis was admitted with complaints of multiple joint pain, swelling, migratory arthritis, neck stiffness, and fever of 1 week's duration. The patient gave a history of exposure to insect/mosquito bites. There was no prior history of arthritis. His spouse claimed to have noted slight depression in the patient's mental status. Positive physical findings include temperature 102°F, neck stiffness with pain on flexion, 3/6 systolic murmur at mitral/tricuspid area, right wrist and left ankle joint swollen, and tender, right shoulder joint tender, with limited range of motion. ECG showed right bundle branch block. Laboratory data showed leukocytosis with left shift, normal uric acid, elevated ESR, CRP, RF. ANA negative. Arthrocentesis from the left ankle joint showed cloudy aspirate with RBC 400/mm2, WBC 18,050/mm2 with 100% polys. Joint fluid positive for negatively birefringent crystals. CSF studies negative for Gram stain, B. burgdorferi Ab, West Nile Ab, oligoclonal bands, and myelin basic protein. The patient was started on indomethacin with significant recovery of symptoms, and antibiotics were discontinued after negative test results.
Discussion The initial presentation of our patient with multiple joint pain and swelling with neck stiffness and high-grade fever is an uncommon presentation of gouty arthritis. The involvement of the shoulder and the spine, along with a history of travel and exposure to insect/mosquito bite, caused diagnostic confusion.
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