Polyarticular tophaceous gouty arthritis
A 45-year-old male was presented with long standing history of pain, swelling and deformity of small and large joints of both hands and feet for approximately 12 years. He was put on allopurinol for 6 months and dietary restriction of protein on account of hyperuricemia with serum uric acid levels of 12.43 mg/dL. Patient intentionally interrupted the treatment following his betterment of health. When the patient visited the outpatient department on first physical examination, he was conscious, a febrile, and normotensive. Cardiovascular and respiratory system parameters were normal.
The most likely diagnosis in this case is
- Rheumatoid arthritis
Gout is a metabolic disorder of purine degradation pathway usually affecting middle aged and elderly men and postmenopausal females. Usually, it results in acute, monoarticular arthritis, intercritical period and chronic tophaceous gout associated with hyperuricemia and characterized by the presence of monosodium urate (MSU) crystals in connective tissues and kidneys.1, 2 However, some patients develop chronic polyarthritis mimicking rheumatoid arthritis. 3–6 Both disease entities have been reported to occur in adult population to the extent of approximately 1% 2,7,8 with symmetric polyarthritis. Symmetrical presentation or positive rheumatoid factor (RF) can be seen in both the diseases. A few cases of polyarticular tophaceous gout have been reported in literature.9,10 We report a rare case of a 45-year-old male with polyarticular tophaceous gout with atypical involvement of hand and feet with disabling effects of untreated hyperuricemia.
The patient reported with the history of polyarthralgia which had improved in a week. This was followed by frequent intermittent episodes of arthritis of small and large joints of hands, knees, wrists, ankles and feet without morning stiffness. It was treated symptomatically with non-specific non-steroid anti-inflammatory drugs (NSAIDs) leading to the improvement over a period of time. Thereafter, patient developed recurrent episodes of polyarthritis with painless nodules on hand and feet.
Physical Examination & Laboratory Investigations
Physical examination of locomotor system revealed muscle atrophy of all four limbs and interossei muscles of both hands; multiple deformities of wrists, metacarpophalangeal joints (MCP), proximal interphalangeal joints (PIP) of hands and metatarsophalangeal joints of feet. Skin examination showed subcutaneous nodule of different sizes, measuring 1–2 cm along metacarpophalangeal joints (MCP) and proximal interphalangeal joints (PIP) of hands metatarsophalangeal joints feet. These nodules were not showing any signs of inflammation and were fixed to deeper tissues.
Laboratory workup revealed hemoglobin 12.1 g/dL, leukocyte counts 4,300/μL, platelet counts 150x103/ μL, ESR 14/mm Ist hr, uric acid 14 mg /dL, creatinine 1.35 mg/dL, rheumatoid factor (RF) negative and blood glucose fasting 110 mg/dL. Urinary uric acid levels were 1.19 g/24 hr and creatinine clearance of 40 mL/ min/1.73 m2 and C-reactive protein 15 mg/L.
X-ray of hands showed narrowing of joint space, subarticular cysts at proximal interphalangeal joint of middle finger of right hand with asymmetric soft tissue swelling. X-ray of feet showed narrowing of joint spaces bilaterally with subarticular cysts and overhanging edges. There was complete osteolysis of little toe of right foot.
Histopathological examination of nodule removed from left MCP joint revealed presence of uric acid crystals (tophus) with no atypical cells.
A diagnosis of polyarticular tophaceous gout was made and patient was treated with colchicine 0.5 mg/day and febuxostat 40 mg/day, which was increased to 1 mg/day and 80 mg/day respectively till acute stage. Currently, patient is showing good response with febuxostat 80 mg/ day alone.
Gout is an inflammatory arthropathy affecting 2.13% of population in United States of America in 2009 11 mostly in old age, males, postmenopausal females and black race. 12 It is a metabolic disorder, characterized by elevation of uric acid levels above 6.8 mg/dL and needle shaped crystal of monosodium urate from super saturated fluids that deposit in tissues resulting gouty arthritis, tophi formation, uric acid nephrolithiasis and renal impairment. 14, 15 Some studies reveal the decrease in serum urate levels achieved by urate lowering drugs and the fast reduction in tophaceous deposition. 16 Surgical treatment is seldom required for gout and is usually reserved for cases of recurrent attacks with deformities, severe pain and joint destruction. 17 The main indication of surgical intervention in gout is sepsis or infection and mechanical problems.18 Radiologic changes in gouty arthritis are asymmetrical, erosive arthritis with preserved articular surface except in late cases. Bone erosions are mainly caused by tophi deposits. 10 Almost 30% of patients of rheumatoid arthritis have subcutaneous nodes and all these patients are usually seropositive. Thus polyarthritis with subcutaneous nodules with negative rheumatoid factor should be investigated for tophaceous gout.19 Early diagnosis and initiation of early treatment of gouty arthritis will halt the progression of disease to tophaceous state. The current medical management of gouty arthritis has changed a lot. At present management of gout includes non-steroid anti-inflammatory drugs (NSAIDs), colchicines and steroids.
The intraarticular steroid has been main stay to alleviate acute gouty arthritis. It is pertinent to mention interleukin 1 beta inhibitors are the future for amelioration of gouty syndrome. Rilonacept, an interleukin 1 antagonist has proven to be of great advantage in chronic gout and helpful in refractory gout but randomized control trails need to be done for its effectiveness.
Polyarticular tophaceous gouty arthritis is uncommon considering pharmacological treatment of hyperuricemia and such cases may be considered as differential diagnosis for rheumatoid arthritis so that early treatment will stop the disability effects in such patients.
- Cassetta M, Gorevic PD. Crystal arthritis: gout and pseudogout in the geriatric patient. Geriatrics 2004;59(9):25–30.
- Kuo CF, Tsai WP, Liou LB. Rare copresent rheumatoid arthritis and gout:comparison with pure rheumatoid arthritis and a literature review. Clin Rheumatol 2008;27(2):231–5.
- Baker DL, Stroup JS, Gilstrap CA. Tophaceous gout in a patient with rheumatoid arthritis. J Am Osteopath Assoc 2007;107(12):554–6.
- Gomez MM, Carvajal JJD, Pastor MAAC. Gota tofácea: Indisciplina o desconocimiento? Medifam 2002;12(4):289–2.
- Wooten M. Seronegative rheumatoid arthritis and gout. Clin Rheumatol 2005;24(1):91.
- Reginato AJ. Gota e outras artropatias causadas por cristais. In: Kasper DL,Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL. Harrinson. Medicina Interna. v. 2, 16 ed., Rio de Janeiro: McGraw-Hill Interamericanado Brasil Ltda., 2006, pp. 2146–51.
- Bachmeyer C, Charoud A, Mougeot-Martin M. Rheumatoid nodules indicating seronegative rheumatoid arthritis in a patient with gout. Clin Rheumatol 2003;22(2):154–5.
- Khosla P, Gogia A, Agarwal PK, Pahuja A, Jain S, Saxena KK. Concomitant gout and rheumatoid arthritis—a case report. Indian J Med Sci 2004;58(8):349–52.
- Schapira D, Stahl S, Izhak OB, Balbir-Gurman A, Nahir AM. Chronictophaceous gouty arthritis mimicking rheumatoid arthritis. Semin Arthritis Rheum 1999;29(1):56–3.
- Talbott JH, Altman RD, Yü TF. Gouty arthritis masquerading as rheumatoid arthritis or vice versa. Semin Arthritis Rheum 1978;8(2):77–114.
- Brook RA, Forsythe A, Smeeding JE, Lawrence Edwards N. Chronic gout: epidemiology, disease progression, treatment and disease burden. Curr Med Res Opin 2010;26(12):2813–1.
- Neogi T. Clinical practice. Gout. N Engl J Med 2011;364(5):443–52.
- Lee SJ, Terkeltaub RA, Kavanaugh A. Recent developments in diet and gout. Curr Opin Rheumatol 2006;18(2):193–8.
- Touart DM, Sau P. Cutaneous deposition diseases. Part II. J Am Acad Dermatol 1998;39(4 Pt 1):527–44.
- Emmerson BT. The management of gout. N Engl J Med 1996;334(7):445–1.
- Perez-Ruiz F, Calabozo M, Pijoan JI, Herrero-Beites AM, Ruibal A. Effect of urate-lowering therapy on the velocity of size reduction of tophi in chronic gout. Arthritis Rheum 2002;47(4):356–60.
- Khandpur S, Minz AK, Sharma VK. Chronic tophaceous gout with severe deforming arthritis. Indian J Dermatol Venereol Leprol 2010;76(1):69–71.
- Kumar S, Gow P. A survey of indications, results and complications of surgery for tophaceous gout. N Z Med J 2002;115(1158):U109.
- Bertolo MB, Brenol CV, Schainberg CG, et al. Atualizacao do consensoBrasileiro no Diagnosticoe Tratamento da Artrite Reumatoide. Rev Bras Reumatol 2007;47(3):151-9.