Tophaceous Gout in a Patient with Rheumatoid Arthritis
A 50-year-old white woman with severe anemia was transferred from an outlying medical center to the Oklahoma State University (OSU) Medical Center in Tulsa. The patient complained of shortness of breath, severe fatigue and her wrists and knees were bilaterally swollen and tender.
The most likely diagnosis of this presentation is
- Rheumatoid Arthritis
Gout is a common chronic, systemic, inflammatory disease caused by the overproduction of uric acid and may have presentation similar to rheumatoid arthritis (RA).1, 2 RA affects the synovial membranes and causes muscle atrophy and bone weakness which may lead to significant debilitation in patients if not identified early and managed appropriately.3
Tophaceous gout is a less common condition that causes skin lesions called tophi. It occurs in patients with chronic gout and has been reported on finger pads, arms, thighs, buttocks, and the abdomen.4 These lesions are usually painless but may ulcerate and drain with a white, chalky, urate matter.5 There is a rare occurrence of concomitant gout and RA.
Medical history was significant for RA gout, depression, and hypertension. The patient was on various medications, including adalimumab injections for RA (40 mg every other week), allopurinol tablets for gout (300 mg twice daily), amitriptyline hydrochloride tablets for depression (150 mg/d at bedtime), clonidine tablets for hypertension (0.2 mg daily), and acetaminophen tablets for pain. Four units of packed red blood cells were also administered for anemia just before she was transferred to the OSU Medical Center.
Examination and Laboratory Investigation
Physical Examinations: On examination, the patient was noted as obese, alert and oriented, and in no acute distress. She had multiple pustules with a yellow center on abdomen and fingers. Her wrists and knees were bilaterally swollen and tender, and she complained of decreased range of bilateral motion in metacarpophalangeal joints.
Laboratory Investigations: Laboratory test revealed a creatinine value of 1.8 mg/dL; ESR 106 mm/h; white blood cell count 15,200/μL and hemoglobin 9.6 g/dL.
Imaging Studies: Radiographic scans of the hands revealed bilateral juxta-articular osteopenia involving metacarpophalangeal regions and bilateral symmetric radial and ulnar carpal joint space loss with associated erosive changes consistent with RA. Radiographic scans of the feet also uncovered symmetric joint space narrowing with osteopenia. A wet mount specimen with polarized light microscopy of the punch biopsy for an abdominal skin lesion revealed monosodium urate crystals, indicative of tophaceous gout.
Because of the previous noncompliance with prescribed medications, the patient's daily dose of amitriptyline was changed to 75 mg. On day 2 of admission, an esophagogastroduodenoscopy was performed, which showed mild antral gastritis. The patient was administered pantoprazole sodium, 40 mg/d, for gastritis, severe anemia and to prevent gastrointestinal bleeding. Ceftriaxone sodium, 1 g/d, as empiric therapy was administered for elevated WBC and fever. All other medications were continued as previously described.
Laboratory results revealed a rheumatoid factor of <20 IU/mL; reticulocyte count, 3.08%; lactate dehydrogenase, 263 U/L; serum uric acid, 6.8 mg/dL; 24-hour urine protein, 2074 mg; and 24-hour urine uric acid, 432 mg. The low rheumatoid factor indicated seronegative RA. A combination therapy of prednisone, 40 mg/d, and colchicine, 0.6 mg/d was administered for her rheumatologic conditions.
Despite of patient's normal uric acid levels, tophaceous gout was also diagnosed due to presence of monosodium urate crystals. The patient's elevated lactate dehydrogenase level and reticulocyte count indicated hemolytic anemia. Results from a peripheral smear suggested normocytic anemia with granulocytosis and thrombocytosis. However, this result may be attributed to the fact that the smear was performed after administration of steroids and packed red blood cells.
The patient was discharged after 6 days in stable condition and there was decrease in shortness of breath, fatigue, and joint pain, as well as improved but not completely resolved tophi lesions. Because of the high serum creatinine level and patient's noncompliance with previous home medication regimen, the daily dose of allopurinol was decreased to 100 mg. Similarly, colchicine (0.6 mg/d) was used as an acute therapy and as a prophylactic agent with the “initiation” of allopurinol therapy. Other medications on discharge included prednisone, 40 mg/d for 2 weeks, and weekly doses of alendronate, 70 mg, and etanercept, 50 mg.
The reason for the lack of coexistence between RA and gout is still disputed. Hyperuricemia may produce an immunosuppressive effect on RA because rheumatoid factor is decreased in these patients.11 High concentrations of uric acid may function as an antioxidant and a free radical scavenger.12 There is also evidence to suggest that monosodium urate crystals may bind antigens such as immunoglobulin G and may block the activation of B and T cells, which are prominent in patients with RA.12
Tophaceous gout is a rare clinical manifestation that has been observed in patients with a history of chronic gout. Although chronic gout and RA are common clinical entities, they seldom coexist.2,6-8 Understanding of similar presentations of both conditions can help physicians in better diagnosis and treatment.
- Terkeltaub RA. Gout. N Engl J Med. 2003; 349:1647-1655.
- Zonana-Nacach A, Alarcón GS, Daniel WW. Rheumatoid arthritis preceding the onset of polyarticular tophaceous gout [letter]. Ann Rheum Dis. 1996; 55:489-490.
- O'Dell JR. Therapeutic strategies for rheumatoid arthritis. N Engl J Med. 2004; 350:2591-2602.
- Fam AG, Assaad D. Intradermal urate tophi. J Rheumatol. 1997; 24:1126-1131.
- Vázquez-Mellado J, Cuan A, Magaña M, Pineda C, Cazarín J, Pacheco-Tena C, et al. Intradermal tophi in gout: a case-control study. J Rheumatol. 1999; 26:136-140.
- Gordon TP, Ahern MJ, Reid C, Roberts-Thomson PJ. Studies on the interaction of rheumatoid factor with monosodium urate crystals and case report of coexistent tophaceous gout and rheumatoid arthritis. Ann Rheum Dis. 1985; 44:384-389.
- Raman D, Abdalla AM, Newton DRL, Haslock I. Coexistent rheumatoid arthritis and tophaceous gout: a case report. Ann Rheum Dis. 1981; 40:427-429.
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- Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988; 31:315-324.
- Schapira D, Stahl S, Izhak OB, Balbir-Gurman A, Nahir AM. Chronic tophaceous gouty arthritis mimicking rheumatoid arthritis. Semin Arthritis Rheum. 1999; 29:56-63.
- Bachmeyer C, Charoud A, Mougeot-Martin M. Rheumatoid nodules indicating seronegative rheumatoid arthritis in a patient with gout. Clin Rheumatol. 2003; 22:154-155.
- Spector AK, Christman RA. Coexistent gout and rheumatoid arthritis. J Am Podiatr Med Assoc. 1989; 79:552-558.