Abstract

Gouty arthritis is the most common microcrystalline arthropathy, typically presenting as a monoarticular and peripheral condition. Axial involvement, particularly of the spine and sacroiliac joints, is rare and can mimic other pathologieS, such as neoplastic lesions. We report the case of a 67-year-old woman with a history of metabolic syndrome, renal lithiasis, severe gouty arthritis requiring toe amputations, and an allergy to allopurinol. She was admitted following an L1 vertebral fracture due to a fall, which was managed conservatively. Physical examination revealed multiple subcutaneous hardened nodules consistent with gouty tophi, one with sandy exudate. Imaging studies showed sacroiliac joint alterations and lytic lesions in L4-L5, initially raising suspicion of neoplastic infiltration. Further findings included an atrophic left kidney suggestive of xanthogranulomatous pyelonephritis. Laboratory workup revealed moderate hyperuricemia and elevated inflammatory markers. A biopsy of the sacroiliac joint confirmed gouty tophi. Treatment included dose escalation of Febuxostat and comprehensive risk factor management, resulting in significant clinical improvement at one-month follow-up. This case underscores the importance of considering gouty arthritis in the differential diagnosis of osteolytic spinal and sacroiliac lesions. Targeted biopsy was crucial in confirming the benign nature of the condition. Early recognition and individualized treatment can lead to favorable outcomes even in complex presentations of gout.