The Rheumatologist
COVID-19 NewsACR Convergence
  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed
  • Home
  • Conditions
    • Rheumatoid Arthritis
    • SLE (Lupus)
    • Crystal Arthritis
      • Gout Resource Center
    • Spondyloarthritis
    • Osteoarthritis
    • Soft Tissue Pain
    • Scleroderma
    • Vasculitis
    • Systemic Inflammatory Syndromes
    • Guidelines
  • Resource Centers
    • Axial Spondyloarthritis Resource Center
    • Gout Resource Center
    • Psoriatic Arthritis Resource Center
    • Rheumatoid Arthritis Resource Center
    • Systemic Lupus Erythematosus Resource Center
  • Drug Updates
    • Biologics & Biosimilars
    • DMARDs & Immunosuppressives
    • Topical Drugs
    • Analgesics
    • Safety
    • Pharma Co. News
  • Professional Topics
    • Ethics
    • Legal
    • Legislation & Advocacy
    • Career Development
      • Certification
      • Education & Training
    • Awards
    • Profiles
    • President’s Perspective
    • Rheuminations
    • Interprofessional Perspective
  • Practice Management
    • Billing/Coding
    • Quality Assurance/Improvement
    • Workforce
    • Facility
    • Patient Perspective
    • Electronic Health Records
    • Apps
    • Information Technology
    • From the College
    • Multimedia
      • Audio
      • Video
  • Resources
    • Issue Archives
    • ACR Convergence
      • Gout Resource Center
      • Axial Spondyloarthritis Resource Center
      • Psoriatic Arthritis
      • Abstracts
      • Meeting Reports
      • ACR Convergence Home
    • American College of Rheumatology
    • ACR ExamRheum
    • Research Reviews
    • ACR Journals
      • Arthritis & Rheumatology
      • Arthritis Care & Research
      • ACR Open Rheumatology
    • Rheumatology Image Library
    • Treatment Guidelines
    • Rheumatology Research Foundation
    • Events
  • About Us
    • Mission/Vision
    • Meet the Authors
    • Meet the Editors
    • Contribute to The Rheumatologist
    • Subscription
    • Contact
  • Advertise
  • Search
You are here: Home / Articles / Image Case Report: Milk of Urate Bulla

Image Case Report: Milk of Urate Bulla

October 10, 2022 • By Samantha C. Shapiro, MD

  • Tweet
  • Email
Print-Friendly Version / Save PDF

FIGURE 1: Milk of urate bulla. (Click to enlarge.)

A 60-year-old Black woman with a history of stage 3 chronic kidney disease, type 2 diabetes and hypertension presented with a 12-month history of asymmetric polyarthritis of the wrists, metacarpophalangeal (MCP), proximal interphalangeal (PIP), metatarsophalangeal (MTP) and knee joints.

You Might Also Like
  • Case Report: Does a Young Woman with Gitelman Syndrome Have Gout?
  • Case Report: CPPD Presenting as Pseudosepsis
  • Case Report: Not All Crystals Are Gout
Explore This Issue
October 2022
Also By This Author
  • Highlights from the ACR Review Course 2022

The review of systems was unremarkable. She denied oral ulcers, rashes, alopecia, or a history of pleural or pericardial effusions. She denied a history of psoriasis, dactylitis, inflammatory back pain, uveitis, abdominal pain, melena or hematochezia. There was no history of podagra, tophi or acute monoarthritis.

ad goes here:advert-1
ADVERTISEMENT
SCROLL TO CONTINUE

Laboratory studies were notable only for a positive anti-nuclear antibody at a titer of 1:80 with a homogenous pattern, and an elevated serum urate level of 9.5 mg/dL. She had chronic creatinine elevation, normocytic anemia and proteinuria attributed to diabetic nephropathy. Extractable nuclear antigens, complement levels, rheumatoid factor and anti-cyclic citrullinated peptide were negative.

In October 2018, treatment with adalimumab and prednisone was initiated with improvement of synovitis, but the patient’s disease flared upon tapering of the glucocorticoids. In July 2019, she presented to the clinic in tears, with acute monoarthritis of the right knee. She was unable to bear weight.

ad goes here:advert-2
ADVERTISEMENT
SCROLL TO CONTINUE

Arthrocentesis revealed inflammatory synovial fluid with 40,000 white blood cells/µL (neutrophil predominant). Gram stain, bacterial cultures and crystals were negative. She responded positively to glucocorticoids. Over the next year, her disease remained active in the hands, feet and knees, with minimal response to etanercept, tofacitinib or tocilizumab.

In October 2020, the patient returned to the clinic with hard, sub-centimeter, white lesions on her finger pads. A warm effusion of her left first MTP joint and a white blister on her left second toe were also noted on examination (see Figure 1). There was no sclerodactyly, Raynaud’s phenomenon or muscle weakness. Nailfold capillaries, muscle strength and creatinine kinase levels were normal.

Aspiration of the first MTP joint and blister yielded 5 cc of chalky white fluid (see Figure 2). Polarized light microscopy revealed negatively birefringent crystals consistent with monosodium urate. Her serum urate level was 9.7 mg/dL. Repeat radiographs of both hands and feet showed interval erosive changes in both midfeet, consistent with gouty arthropathy.

FIGURE 2: Milk of urate aspirated from the first MTP joint and milk of urate bulla. (Click to enlarge.)

Allopurinol was initiated and titrated to a goal serum urate of less than 6.0 mg/dL, per the 2020 ACR Guideline for the Management of Gout.1 Five milligrams of prednisone by mouth daily was continued as flare prophylaxis.

Pages: 1 2 | Single Page

Filed Under: Conditions, Crystal Arthritis Tagged With: case report, Gout, milk of urate bullaIssue: October 2022

You Might Also Like:
  • Case Report: Does a Young Woman with Gitelman Syndrome Have Gout?
  • Case Report: CPPD Presenting as Pseudosepsis
  • Case Report: Not All Crystals Are Gout
  • Fellows’ Forum Case Report: Tophaceous Bullae

ACR Convergence

Don’t miss rheumatology’s premier scientific meeting for anyone involved in research or the delivery of rheumatologic care or services.

Visit the ACR Convergence site »

Simple Tasks

Learn more about the ACR’s public awareness campaign and how you can get involved. Help increase visibility of rheumatic diseases and decrease the number of people left untreated.

Visit the Simple Tasks site »

Rheumatology Research Foundation

The Foundation is the largest private funding source for rheumatology research and training in the U.S.

Learn more »

The Rheumatologist newsmagazine reports on issues and trends in the management and treatment of rheumatic diseases. The Rheumatologist reaches 11,500 rheumatologists, internists, orthopedic surgeons, nurse practitioners, physician assistants, nurses, and other healthcare professionals who practice, research, or teach in the field of rheumatology.

About Us / Contact Us / Advertise / Privacy Policy / Terms of Use / Cookie Preferences

  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed

Copyright © 2006–2023 American College of Rheumatology. All rights reserved.

ISSN 1931-3268 (print)
ISSN 1931-3209 (online)