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Gout Presenting as Acute Flexor Tenosynovitis Mimicking Infection.

A 48-year-old, right-hand-dominant secretary presented with a 5-day history of pain and swelling in the right index finger in the absence of any trauma and with no systemic upset. She had no relevant medical history, and her regular medications included furosemide, taken intermittently for lymphedema. She was a nonsmoker, and her alcohol intake was within recommended limits. Initial examination revealed all 4 Kanavel signs of pyogenic flexor tenosynovitis: fusiform swelling of the digit and held in flexion, pain on passive extension, and palpation along the flexor sheath. The patient was admitted for intravenous antibiotics and elevation with a working diagnosis of pyogenic flexor tenosynovitis. The flexor tenosynovitis was managed operatively with 3 washouts of the right index finger over a period of 2 weeks. Turbid fluid was seen initially with frank pus at the second operation. A third washout did not reveal pus, and the patient improved clinically. Microbiology from all 3 washouts was negative; however; the patient was being treated with antibiotic therapy throughout each perioperative period. The patient returned 1 month later with persistent pain and swelling of the right index finger, which was deteriorating despite empirical oral antibiotics. Kanavel’s cardinal signs were again present. The decision was made to undergo a fourth exploration and washout of the flexor tendon sheath. The appearance of the right index finger prior to the fourth operation is shown in Figure 1. A plain radiograph revealed soft tissue swelling but no evidence of osteomyelitis. At operation, there were multiple caseous deposits within the subcutaneous tissue, synovium, and substance of both flexor tendons. There was no pus or turbid fluid. Histological examination of the synovium demonstrated chronically inflamed fibrous tissue with deposits of noncellular material with a suggestion of needle-shaped crystal “ghosts,” highly suggestive of gout. Concomitant laboratory investigations revealed a uric acid level of 546 μmol/L (reference range, 140–360 μmol/L), C-reactive protein of 4.6 mg/L, and white blood cell count of 8.1 10/L. Microbiological investigations were all negative. The patient was urgently assessed by rheumatology who performed a bedside ultrasound (Fig. 2), which confirmed the marked gouty deposition overlying and within the finger flexor tendon complex. There was marked soft tissue disruption with positive Doppler signal indicating active inflammation. These