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A case of chronic tophaceous gout with rare large tophi

A case of chronic tophaceous gout with rare large tophi A case of chronic tophaceous gout with rare large tophi
A case of chronic tophaceous gout with rare large tophi A case of chronic tophaceous gout with rare large tophi

A 67-year-old man presented to the clinic complaining of generalized articular pain and multiple large firm tophi. He had consumed herbal medicines to treat the painful symptoms. The swelling gradually increased in size from the past four years. None of his close relatives had gout. However, the patient had a personal history of alcohol abuse, and his diet included high purine content. The patient was a worker in a chemical factory earning daily wedges.


The most likely diagnosis of this presentation is

  • Arthritis
  • Gout
  • Infection


Gout refers to painful inflammatory arthritis indicated by elevation of uric acid levels, causing deposition of monosodium urate (MSU) crystals in joints, cartilage, and soft tissues. Gout is known to be the most common type of inflammatory arthritis in adults. Common symptoms may include painful attacks of peripheral joint synovitis, limited movement of the diseased joint, and inflammation, while joint damage and tophus deposition can eventually develop. Tophi are reported to develop in approximately 12-35% of patients with gout and may lead to significant complications including ulceration, infection and nerve compress. However, chronic tophaceous gout develops after ten years of recurrent polyarticular gout. The burden of gout is gradually increasing around the globe, especially in developed countries. Common risk factors for tophaceous gout include older age, male sex, obesity, alcohol abuse, diabetes mellitus, hyperlipoproteinemia, socioeconomic status, black race, and congestive heart failure.

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Key take away

Patient with an 8-year history of untreated gout developed large tophi, confirming the diagnosis of chronic tophaceous gout. Allopurinol, along with colchicine, provided significant relief in joint pain.

Medical history

The patient had an 8 years old history of untreated gout and no family history of gout. The patient had a personal history of alcohol abuse, and his diet included high purine content. 

Examination & lab investigations

The physical examination revealed multiple large tophi (ulcerated and discharged white chalky material) on the hands, feet, elbows, and knees. Laboratory assessments showed significantly elevated serum uric acid (96 mg/l). The findings of the liver function test were found to be normal. The x-ray exam revealed inflammation of the soft tissues, destruction of the first left metatarsophalangeal joint and periarticular erosions in interphalangeal joints. Abdominal ultrasound revealed caliceal calculi on both sides.

Management

Treatment approach aimed to decrease serum uric acid level, thereby resolving painful symptoms. Allopurinol (100mg/day) along with colchicine (1mg/day) was given to the patient. His diet was controlled and strictly observed. Joint pain and other severe symptoms were resolved on the fourth day of the treatment.

Discussion

If left untreated or poorly managed, gout can lead to the formation of tophi. Therefore, early accurate diagnosis and appropriate treatment are crucial. Although the diagnosis of MSU crystals is the gold standard for gout diagnosis, it is often difficult in the early stage of the disease. Tophi can occur either in the presence or absence of gouty arthritis and mainly affects the helix of the ears, on fingers, toes, wrists and knees, and the heel cord.

Treatment approaches for Gout include urate-lowering therapy (ULT) such as allopurinol, complementary medicines and alternative therapies. However, a combination of pharmacological treatments and diet modification is considered to be an ideal approach to treat gout. Rarely, the patients may require a surgical procedure in case of severe deformities, frequent attacks of chronic pain, joint destruction, altered tendon functions, skin necrosis and ulceration.

Learning

The early treatment of gout is warranted to avoid the further complications of gout-like chronic tophi causing new joint deformities.

References

    1. Alan N. Baer, Tracie Kurano, Uma J. Thakur, et al. Dual-energy computed tomography has limited sensitivity for non-tophaceous gout: a comparison study with tophaceous gout. BMC Musculoskelet Disord. 2016; 17: 91.
    2. Kuo CF, Grainge MJ, Zhang W. Global epidemiology of gout: prevalence, incidence and risk factors. Nat Rev Rheumatol. 2015 Nov;11(11):649-62.
    3. Singh JA, Shah N, Edwards NL. A cross-sectional internet-based patient survey of the management strategies for gout. BMC Complement Altern Med. 2016 Mar 1;16(1):90.
    4. Kasper IR, Juriga MD, Giurini JM, et al. Treatment of tophaceous gout: When medication is not enough. Semin Arthritis Rheum. 2016 Jan 29. pii: S0049-0172(16)00041-X.
    5. Aradoini N, Talbi S, Berrada K,et al. Chronic tophaceous gout with unusual large tophi: case report. Pan Afr Med J. 2015 Oct 13;22:132.
    6. Sugiura M, Aoki A. An elderly man presenting polyarthritis diagnosed as chronic tophaceous gout. Nihon Ronen Igakkai Zasshi. 2015;52(4):415-20.

Source:

Pan Afr Med J. 2015; 22: 132.

Article:

Chronic tophaceous gout with unusual large tophi: case report

Authors:

Nassira Aradoini et al.

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