1. SEVERE DISSEMINATED CUTANEOUS GOUT -CASE REPORT- Irina Tudose1, Olguta Anca Orzan2, Diana Petrache2, Prof. Dr. Calin Giurcaneanu2 1 Pathology Department, Elias University Emergency Hospital, Bucharest 2 Dermatology Department, Elias University Emergency Hospital, Bucharest  We present the case of a 53-year-old obese caucasian male with a history of severe hyperuricemia and acute gouty arthritis; frequent hunter and consumer of venison Chief complaints: disseminated yellow skin nodules dating for about five years with an accelerated development of the lesions during the last year. Histopathological examination (2010): chronic granulomatous inflammatory process, endogenous foreign body, most likely dermal calcinosis

2.  Grade III obesity (BMI = 43 kg/m2)  Joint swelling (right knee joint and bilateral hand interphalangeal joints)  No lung rales, BP = 130/80 mm Hg, AV = 80/min  no bowel obstruction, occasionally rectorhagia  inflammatory syndrome (ESR = 96 mm/h, Fb = 475 mg/dl)  anemia (Hb = 10 g/dl, Ht = 32.2%)  nitrogen retention (creatinine = 1.83 mg/dl)  uric acid = 11.45 mg/dl  mild hyperkalemia  proteinuria (1.2 g/24 h) Past medical history (PMH): Gouty arthritis (1996) – inconsistently treated Focal segmental glomerulosclerosis (renal biopsy, 2003) Chronic renal failure Moderate chronic anemia Essential hypertension (2004) Medication: Verapamil, Furosemide Family history (FH): not significant.

3. Clinical examination Multiple disseminated nodules, 1-15 mm diameter, some of them ulcerated and draining a white chalky material

4. Histopathological examination Usual and special stains:  Haematoxilin-eosin  Periodic acid Schiff (PAS)  Gömöri stain – for reticulin fibers  Von Kossa stain – for calcium deposits  Red of Congo – for amiloid  Elastic Von Gieson – for elastic fibers  Polarized light examination Histopathological description: Two pieces of skin showing dermal granulomatous chronic inflammation with numerous multinucleated giant cells of "foreign body" and foamy macrophages located around focal areas of extensive deposition of amorphous material, acellular, pale-basophilic with focal areas of central suppurative necrosis. After using special stains, it was established that histopathological appearance is compatible with the diagnosis of gout.

5. HEx40 Large areas of amorphous acellular, pale-basophilic material deposition surrounded by chronic granulomatous inflammation HEx200

6. Von K x200 Von Kossa Stain - for the evidence of calcium salts, absent in this case vGx200 Van Gieson stain – for elastic fiber, preserved in the periphery areas of amorphous material deposition Gömöri stain – for reticulin fibers Gx400 Red of Congo – for amiloid, absent in this case RCx400

7. Calcinosis cutis universalis: deposits of calcium phosphate crystals in the tissues Von Kossa Rheumatoid nodules: areas of fibrinoid necrosis board of chronic granulomatous inflammation Differential diagnosis PAS

8. Polarized light examination : A few monosodium urate crystals were found because of the formalin 10% preservation of the sent specimens Particularities of the case  Rare disease Davis L. Disseminated cutaneous gout: A rapid onset of disease. J Am Acad Dermatol 2011; 64 (2 Supp 1); AB113;  Severity form (uric acid: 7.87 mg/dl → 16.1 mg/dl) and the long term evolution (15 years)  Focal segmental glomerulosclerosis associated