Neurological Disorders

Intradural Tophaceous Gout of the Cavernous Sinus and Spine: Case Report and Review of Literature

Abstract

Reinard KA, Felicella MM, Zakaria HM and Rock JP

Background: Purine-rich diets and improper metabolism of uric acid result in deposition of monosodium urate crystals in multiple organs throughout the body. Gout is typically characterized by recurrent attacks of inflammatory arthritis; however, deposition of uric acid crystals in the spinal canal may result in debilitating back pain, neural compression, and progressive myelopathy. While extradural gout is a widely reported source of spinal cord compression, we present a novel case of an individual with intradural tophaceous gout in the cranial and spinal cavities. Case history: A 61-year-old African-American male presented with diplopia, masticatory difficulty, and facial pain. Serial imaging revealed an enlarging, heterogeneously enhancing mass in the left cavernous sinus with extension into the superior orbital fissure and foramen ovale, raising suspicion for a meningioma. Successful surgical resection of the cavernous lesion was undertaken to eliminate the risk of permanent ophthalmoplegia and blindness. The pathological findings were felt to be compatible with chondroma. Nine years later, after stable yearly imaging follow-up of the cranial lesion, the patient presented with progressive myelopathy. Imaging of the spine revealed enhancing, intradural lesions suggestive of calcified meningiomas. Surgical resection was undertaken to preserve motor function. Histopathologic diagnosis after spinal decompression was tophaceous gout. Retrospective review of the cranial pathology indicated that this lesion, too, was consistent with tophaceous gout. Conclusion: The pathophysiology of spinal tophaceous gout is well known and extradural lesions are not uncommon. However, multifocal intradural tophi involving intracranial and intraspinal compartments have not been previously reported. This case represents the first reported case of both intracranial and intraspinal intradural tophaceous gout causing neurological deficits.