A Case of Chronic Tophaceous Gout With Rare Large Tophi

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SCIENCE
A Case of Chronic Tophaceous Gout With Rare Large Tophi

A 69-year-old man presented to the clinic complaining generalized articular pain and multiple large firm tophi. The patient was a worker in a chemical factory earning daily wedges.  He was living with an untreated gout for past 10 years; however, he had consumed herbal medicines to treat the painful symptoms.  The swelling was gradually increaseding in size for past five years. None of his close relatives had gout or any family history of having it. However, patient had a personal history of alcohol abuse and  his diet included high purine content.  

The most likely diagnosis of this presentation is

  • Arthritis
  • Gout
  • Infection

Introduction

Gout refers to a painful inflammatory arthritis indicated by elevation of uric acid levels causing deposition of monosodium urate (MSU) crystals in joints, cartilage, and soft tissues. 1,2 It is the most prevalent type of inflammatory arthritis in adults. Common symptoms may include painful attacks of peripheral joint synovitis, limited movement of diseased joint, and inflammation, while joint damage and  tophus deposition can eventually develop. 1,3 Tophi is reported to develop in approximately 12-35% of patients with gout and may lead to significant complications including ulceration, infection and nerve compress.4 However, chronic tophaceous gout frequently occurs after 10 years of recurrent polyarticular gout.5 The burden of gout is gradually increasing around the globe,  especially in developed countries.2 Common risk factors for tophaceous goutinclude older age, male sex, obesity, alcohol abuse, diabetes mellitus, hyperlipoproteinemia, socioeconomic status, black race, and congestive heart failure.2,5,6

Examination

Overall lookup and extensive physical examination revealed multiple large tophi  (ulcerated and discharged white chalky material ) on both the hands, feet, elbows, and knees. He had a history of hypertension which was accidently discovered about a year ago. Laboratory assessments showed significantly elevated serum uric acid (96 mg/l). Liver function test turned out to be normal. The x-ray exam revealed an inflammation of the soft tissues, total destruction of the first left metatarsophalangeal joint and periarticular erosions in interphalangeal joints. Abdominal ultrasound revealed caliceal calculi on both sides.

Treatment

Ttreatment approach aimed to decrease serum uric acid level thereby resolving painful symptoms.The patient was treated with Allopurinol (100mg/day) accompanaid by Colchicine (1mg/day).  His diet was controlled and closely observed. Joint pain and other severe symptoms were resolved on fourth day of the treatment.

Discussion

If left untreated or poorly managed, gout can lead to 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 early stage of the disease.1  Tophi can occur either in presence or absence of gouty arthritis and particularly affects the helix of the ears, on fingers, toes, wrists and knees, and the heel cord.5

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 considdred to be an ideal approach to treat gout.3 Rarely, patient may require surgical approach in case of severe deformatities, frequent attacks of chronic pain, joint destruction, altered tendon functions, skin necrosis and ulceration.5

Learning

The early treatment of gout is warented in order to avoid the further complications of gout like chronic tophi causing further joint deformities.

Reference

  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. 

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