Tophaceous gout of the pubic symphysis: an unusual cause of groin pain

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Abstract
On examination she weighed 120 kg. A gouty tophus was present at the right index finger proximal interphalangeal joint. She was afebrile and normotensive. There was diffuse tenderness in the right groin and she was unable to actively lift the right leg owing to pain. Significant blood results included erythrocyte sedimentation rate 99 mm/1st h, creatinine 0.17 mmol/l, and urate 0.80 mmol/l. Initial investigations were directed at excluding infection. Plain x ray examination of the pelvis showed destruction of the symphysis consistent with osteitis pubis. Comparison with x ray examination from 1991 showed new osteolytic change (figs 1A and B). A computed tomography scan confirmed destructive change and demonstrated a mass anterior to the symphysis pubis (fig 2A). Treatment was started with intravenous amoxycillin/clavulanic acid empirically, but she subsequently became febrile and developed severe right shoulder pain. Blood cultures were negative. A whole body scintigram demonstrated increased activity around the symphysis pubis, at the right index finger, left foot, both shoulders, and within the skull.

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