Antiretrovirals
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Polyarticular gouty arthritis: case report A 53-year-old man developed refractory polyarticular gouty arthritis during antiretroviral therapy (ART) for HIV infection. The man, who had a 10-year history of gout which he usually self-treated with indometacin and colchicine, initiated ART with a combination of efavirenz, emtricitabine and tenofovir [dosages not stated]. One week later, he presented with pain and joint swelling of this left toe, accompanied by pain in his right hip. Radiographic examination of the right hip revealed mild degenerative disease of bilateral hip and lumbar spine. The patient began treatment with colchicine and indometacin, but failed to improve. Four weeks after initiating ART, the man presented with uncontrolled pain and progressive joint swelling. Inflammation was seen in the wrist and elbows, and his creatinine level increased to 1.6 mg/dL. Cotrimoxazole and indometacin were discontinued due to acute renal insufficiency, and his ART regimen was switched to lamivudine/abacavir [Epzicom] 300/600 mg once daily with efavirenz. Arthrocentesis of the left wrist revealed intracellular urate crystals. The patient’s gout was treated with prednisone, allopurinol and oxycodone. Although the man’s renal function normalised, his symptoms worsened to include severe pain and effusion in wrists, knees, right tarsus and phalanges. He was hospitalised with a serum uric acid level of 6.4 mg/dL and an ESR of 105 mm/h. Arthrocentesis with intra-articular corticosteroids was performed in the wrist and knees; the synovial fluid contained numerous intracellular monosodium urate crystals. Wrist and knee cells counts were consistent with inflammatory arthritis. The patient was treated with high-dose methylprednisolone sodium succinate for 7 days. He was discharged after 9 days in hospital, and his gout flare resolved 4 weeks later. During 18 months of follow-up, no further attacks occurred. Author comment: "We postulate that the combination of restoration of neutrophil and macrophage function and both the loss of anti-inflammatory cytokine activity and increase in pro-inflammatory cytokines including IL-1 [interleukin-1] beta with ART may have played a role in the pathogenesis of severe polyarticular gout manifesting as IRIS [immune reconstitution inflammatory syndrome] in this patient." Sebeny PJ, et al. Refractory polyarticular gouty arthritis as a manifestation of immune reconstitution inflammatory syndrome. JCR: Journal of Clinical Rheumatology 16: 40-42, No. 1, Jan 2010. Available from: URL: http:// 803018678 dx.doi.org/10.1097/rhu.0b013e3181c78ddc - USA
0114-9954/10/1307-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved
Reactions 26 Jun 2010 No. 1307
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