A Case of Triple Arthritis: Tuberculosis, MRSA and Gout in One Knee

Aim: To report a case of concurrent tuberculous and bacterial arthritis in chronic tophaceous gout.
Presentation of the Case: A 59-year old Filipino male patient consulted for sensorial changes with four-month progressive swelling of the right knee draining non-foul smelling yellowish discharge with chalky material. He eventually had arthrocentesis of right knee. Blood cultures were all negative. Acid fast bacilli were present both in the synovial fluid and endotracheal aspirate. Endotracheal aspirate grew Mycobacterium tuberculosis. Synovial fluid grew methicillin-resistant Staphylococcus aureus (MRSA). He was treated with prednisone, clindamycin, colchicine, febuxostat, tramadol, and anti-tuberculous medications. He failed to undergo surgery. Patient eventually had fatal myocardial infarction.
Discussion: To our knowledge, this is the first report of concurrent tuberculous and bacterial (MRSA) arthritis in gout.
Conclusion: This case highlights the possible differential diagnoses especially infections among patients with chronic tophaceous gout. Concurrent tuberculosis and bacterial arthritis can complicate the management of these patients. Hence, microbiologic and crystal analysis of synovial fluid is a very important part of the work-up to tailor the early, specific treatment for these patients.