Nail Plate Bx Presentation, 6

8/9/2019 Nail Plate Bx Presentation, 6

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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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Thick Unstained Secti


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ELONGATED URATE-LIKE CRYSTALS OF UNKNOWN ORIGIN

Clinical History

45 year-old female

No history of gout


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 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

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Nail Plate Bx Presentation, 6