Pôster:

Self-medication for the purpose of weight loss is a frequent practise and extremely harmful to health, many medications as well as formulations use diuretics in their composition. Bariatric surgery should be carefully indicated and postoperative follow-up, with nutritional replacement, mandatory. These aspects, when neglected can lead to the emerge of rare pathologies as the case reported.

Case report

Female, 49 years old, was referred to the Rheumatology Reference Service in May/2017, diagnosed with Rheumatoid Arthritis (RA) one year ago, referring at the time of diagnosis, hands and wrists arthritis, Rheumatoid Factor and ACPA negatives, medicated with methotrexate since diagnosis and Infliximab two months ago. History of hypothyroidism, osteoporosis, bariatric surgery in 2011 without clinical follow-up or any nutritional replacements since the procedure. Despite the proposed treatment, the patient maintained complaints of arthritis in the hands, wrists, knees and elbows. At the first moment the prescribed DMARD medication was maintained and requested examinations for diagnostic review. The patient returns in March 2018, presenting punctiform, whitish nodules in fingers and palm of the hands, and wrists of less than 3mm dimensions, and a nodule of about 4cm in diameter in the right elbow and knees arthritis. Content analysis of nodules and synovial knee puncture found the presence of uric acid crystals, demonstrating the lesions as multiples tophus. When asked about self-medication, the patient revealed the chronic use of furosemide (40-160mg/day) for weight control. Oriented suspension of DMARDs and furosemide, and new diagnostic elucidation was started. Complementary examinations: Uric acid (UA):11mg/dL(RR < 6mg/dL), calcium:9,2mg/dL(RR > 8,7mg/dL), parathyroid hormone (PTH):206pg/mL(RR 12-64 pg/mL), 25-OH-vitamin-D:15ng/mL(RR > 20 ng/mL), and nephrocalcinosis in abdominal ultrassound. Evidence of a hyperparathyroidism either secondary to the drug, to post-bariatric chronic hypovitaminosis D or to a parathyroid adenoma demonstrated in scintigraphy. Diagnosis of atypical tophaceous gout secondary to loop diuretic self-medication was considered. Initiated therapy with allopurinol and benzbromarone, and replacement of cholecalciferol. Patient progresses at 8 months with complete resolution of hands tophus and reduction of serum UA(4.2mg/dL) and PTH (68mg/mL).

Conclusion

The polyarticular involvement, similar to RA, caused by tophaceous gout in young women is a rare and atypical event. In such pathologies, we should investigate secondary causes, in the case in question, there was inadvertently self-medication. Metabolic disturbances, nutrient deficiencies and post bariatric state should be considered aggravating in this report. Suspension of the loop diuretic and adequate treatment of hyperuricemia led to complete reversal of tophaceous deposits and remission of the joint.