Post on 30-May-2018
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THE NAIL PLATE BIOPSY MAY PICK UP
GOUT CRYSTALS AND OTHER CRYSTALS
Mariantonieta Tirado, MD,andAldo Gonzlez-Serva, MD
Baptist Health System and Strata Pathology
ServicesBirmingham, AL, and Lexington, MA
USA
13th Joint Meeting of the International Society ofDermatopathology
Miami, March 3-4, 2010
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The detection of urate crystals in nail platebiopsies (NPBs) has not been described
We present 2 cases History of gout
Uric acid crystals extruded subclinically
We introduce the Weaver et als method Retrieval of polarizable urate crystals
Unstained, thick sections of NPBs
Other crystals in NPBs can resemble urates Of unknown origin (hyperlipidemia?) Associated with spongiosis
INTRODUCTION
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Chronic hyperuricemia
Dermal and subcutaneous nodules
Deposition of monosodium urate crystals
Predilection for lower and upper digits andhelical rims of the ears
GOUT IN SKIN: TOPHI
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NAIL CHANGES IN GOUT
CLINICAL (Rail, 1966):
Longitudinal ridging
Breaking
BIOCHEMICAL (Bolliger and Gross, 1953)
Elevated uric acid in toenails of patients with renal impairment
Chronic severe gout
HISTOLOGICAL
No findings have heretofore been described
Current presentation shows first histological evidence of gout in the nails
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Fixed in formalin, crystals dissolve Amorphous pink appearance
Fixed in alcohol, crystals appear intact Closely arranged, brown, negatively birefringent needles
With any fixation, granulomatous reaction around crystals
MICROSCOPICAPPEARANCE OF URATE
CRYSTALS ACCORDING TOFIXATION
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Weaver et al (J Cutan Pathol, 2009) devised amethod to demonstrate urate crystals in formalin-fixed skin biopsies
Detection of urate crystals was achieved by Thicker (4 and10 m), Unstained Coverslipped sections
Results: Urate crystals were recognized in thickerunstained sections
38% (4 m)
48% (10 m)
RETRIEVAL OF BIREFRINGENCE OFURATES IN ROUTINE BIOPSIES
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H&E
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THICK UNSTAINED SECTIONS
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NAIL PLATE BIOPSIES WITHCRYSTALS
All cases: Abnormal toenails, suspicious of tinea unguium
Case 1: Crystals hinted only with PAS stain (clinical hx ofgout)
Case 2: Urate crystals hinted with PAS stain and provenwith Weavers method (and clinical hx of gout)
Case 3: Elongated crystals of unknown origin
Case 4: Spongiosis-related small crystals
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CRYSTALS HINTED ONLY WITH PAS (ANDCLINICAL HX OF GOUT)
Clinical History
90 yo male
History of gout
Dx of tinea unguium was confirmed histologically
Case 1
PAS
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PAS
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NEGATIVE POLARIZATION
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URATE CRYSTALS HINTED WITH PAS STAIN ANDPROVEN WITH WEAVERS METHOD (AND CLINICALHX OF GOUT)
Clinical History
85 year-old female
History of gout
No onychomycosis identified
Case 2
PAS
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PAS
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ick Unstained Sections
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ick Unstained Sections
Thick Unstained Secti
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Thick Unstained Secti
Thick Unstained Secti
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Thick Unstained Secti
ick Unstained Sections
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ick Unstained Sections
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ELONGATED URATE-LIKE CRYSTALS OF UNKNOWN ORIGIN
Clinical History
45 year-old female
No history of gout
No onychomycosis identified
Case 3
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PAS
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PAS
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SPONGIOSIS-RELATED SMALL SOLID CRYSTALS
ClinicalHistory
57 year-old female
No history of gout
No onychomycosis identified
No Weavers method is pursued
Case 4
PAS
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PAS
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GMS
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GMS
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Fluids exude or transude into nail structures
Crystals can be detected in nail plate biopsies
Nail changes and ungual high levels of uric acidhave been demonstrated in the past, but noturate crystals histologically
Demonstration of urate crystals may not needalcohol fixation as the Weavers method mayretrieve them
CONCLUSIONS
Punch cures the Gout the Colic and the Tisick
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Punch cures the Gout, the Colic, and the Tisick