Chronic tophaceous gout with unusual large tophi: case report
Nassira Aradoini1,&, Sofia Talbi1, Khadija Berrada1, Fatima Zahra Abourazzak1,
1Rheumatology Department, Medical School, Sidi Mohammed Ibn Abdellah University, Hassan II University Hospital, Fez, Morocco
Aradoini Nassira, Rheumatology Department, Hassan II University Hospital, Fez, Morocco
Gout is a metabolic disease, which is characterized by acute or chronic arthritis, and deposition of monosodium urate crystals in joint, bones, soft tissues, and kidneys. But large tophi are unsual in chronic gout. We report the case of a 67-year-oldArabman presenting chronic tophaceous gout with unusual large tophi involving multiple joints: hands, feet, elbows, and knees. Laboratory workup revealed elevated serum uric acid (96 mg/l, normal: 20-74 mg/l), with normal renal function test. In untreated patients, chronic tophaceous gout may develop, which is characterized by chronic destructive polyarticular involvement and tophi. The treatment consists to decrease serum uric acid level which eventually allows the regression of tophi.
Gout is a metabolic disease that can manifest as acute or chronic arthritis, and deposition of monosodium urate crystals in joint, bones and different body tissues, including the skin and soft tissues. Rarely, it can present with tophi as an initial manifestation. Chronic tophaceous gout frequently occurs after 10 years or more of recurrent polyarticular gout. Our case is a rare form of tophaceous gout, which presented with generalized tophi.
A 67-year-old Arab man with an 8-years history of untreated gout was admitted for generalized articular pain. Our patient had only taken traditional medicines for joint pains and did not resort to specific therapy for gout. He was noted to have multiple hard swelling. The swelling developed over 4 years, progressively increasing in size. There was no family history of gout, but personal history of alcohol use, and high purine diet intake. Physical examination revealed that there were multiple large firm tophi over bilateral hands, feet, elbows, and knees (Figure 1, Figure 2, Figure 3).Some of them are ulcerated and discharged white chalky material. He had an average built with BMI of 30,4 and hypertension fortuitously discovered.
Laboratory workup revealed elevated serum uric acid (96 mg/l, normal: 20-74 mg/l), with normal renal function test: blood urea 0,4mg/l (normal: 0, 1- 0,5 mg/l) and serum creatinine 10mg/l (normal: 5-18 mg/l). Radiological examination of both hands showed soft-tissue swelling and periarticular erosions in interphalangeal joints (Figure 4). Radiological examination of the feet showed soft tissue swelling and total destruction of the first right metatarsophalangeal joint (Figure 5).Abdominal ultrasonography revealed bilateral caliceal calculi.
The patient was treated with Allopurinol (100mg/day) associated to Colchicine (1mg/day). After 3 days, he experienced relief of the joints pain. Then he was referred to urology care for his kidney stones.
Gout is a disorder of purine metabolism and results from long-standing
hyperuricaemia and urate crystal deposition in various tissues. In the first
stage, it usually affects the first metatarsophalangeal joint and less commonly
other joints. The next most frequent localizations are the midtarsi, ankles,
knees and arms .
Older age, male sex, postmenopausal state and black race are related to a higher
risk for development of the disease. Also, the use of certain medications
may trigger gout (diuretics, cyclosporine, low doses of aspirin, …)
In untreated patients, chronic tophaceous gout may develop, which is characterized
by chronic destructive polyarticular involvement and tophi. Chronic tophaceous
gout frequently occurs after 10 years or more of recurrent polyarticular
gout. Tophi can occur in soft tissue, osseous tissues, ligaments and different
organs and either in presence or absence of gouty arthritis.Tophi are typically
found on the helix of the ears, on fingers, toes, wrists and knees, on the
olecranon bursae, on the Achilles tendons and also rarely on the sclerae,
subconjuctivally  and on the cardiac valves .
The prevalence of gout is much higher in men than in women and rises with age.
Although the prevalence of tophaceous gout, principally the generalized
form of it, has decreased in the past years, the disease still exists likely
due to the absence of an accurate diagnosis and therapy .
Our case is had large tophi, which are unsual in chronic gout.
If left untreated, hyperuricemicpatients (serum urate level ≥ 68 mg/l or
400 µmol/l) can evolve from intermittent arthritis to polyarticular tophaceous
gout with symptoms between attacks. Lowering serum urate levels with xanthine
oxidase inhibitors or uricosuric agents prevents acute flares and tophi development
The recommended target serum uric acid concentration is <60 mg/l (357 µmol/l)
. Although controversial, recommendations have been made
to achieve a target serum urate level <50 mg/l (297 µmmol/l) in severe chronic
gout patients, as this concentration may be associated with greater depletion
of synovial fluid crystals and a reduction in tophus size [6-7].
Surgical treatment is seldom required for gout and is usually reserved for cases
of recurrent attacks with deformities, severe pain, infection and joint destruction
. It's also indicated when tophi are unsightly, painful;
or when it interfere with tendon function or causes skin necrosis and ulceration;
or encroach upon nerves causing symptoms of compression .
The treatment of gout should be undertaken early in order to avoid the evolution of the disease to the chronic tophaceous form responsible joint deformities and their functional consequences. Our case is a rare form of large tophi complicating untreated chronic gout.
The authors declare no competing interests.
All authors read and agreed to the final version of this manuscript and equally contributed to its content and to the management of the case.
Figure 1: large tophi over bilateral hands
Figure 2: large tophi over bilateral feet
Figure 3: large tophus of the elbow
Figure 4: radiography of both hands showing soft-tissue swelling and periarticular erosions in metacarpophalangeal and interphalangeal joints
Figure 5: radiography of the foot showing soft tissue swelling and destruction of the right first metatarsophalangeal joint
- Li EK. Gout: a review of its aetiology and treatment.
Hong Kong Med J. 2004; 10(4): 261-70. PubMed | Google
- Wortmann RL, Kelley WN. Gout and hyperuricemia.Harris
ED, Budd RC, Genovese MC, Firestein GS, Sargent JS, Sledge CB, editors. , eds.
Kelley's textbook of rheumatology, 7th edn Philadelphia, Pennsylvania, USA:
Elsevier Saunders; 2005: 1402-29. PubMed | Google
- Sarma P, Das D, Deka P, Deka AC. Subconjunctivalurate
crystals: a case report. Cornea. 2010;29 (7):830-832. PubMed | Google
- Iacobellis G. A rare and asymptomatic case of mitral valve tophus associated with severe gouty tophaceous arthritis. J Endocrinol Invest. 2004, 27 (4):965-966. PubMed | Google Scholar
- Neogi T. Clinical practice: Gout. N Engl J Med. 2011,
364 (19):443-452. PubMed | Google
- Pascual E, Andrés M, Vela P. Criteria for gout diagnosis?. J Rheumatol. 2013;40(4):356-8. PubMed | Google Scholar
- Harrold L. New developments in gout.CurrOpin Rheumatol. 2013;25(3):304-9. PubMed | Google Scholar
- EvangelosFalidas, Efstathios Rallis, Vasiliki-KalliopiBournia, Stavros Mathioulakis, Emmanouil Pavlakis and Constantinos Villias. Multi articular chronic tophaceous gout with severe and multiple ulcerations: a case report. Journal of Medical Case Reports. 2011, 5:397. PubMed | Google Scholar
- William Larmon A, James Kurtz F. The Surgical Management
of Chronic Tophaceous Gout.J Bone Joint Surg Am. 1958 Jul;40(4):743-772. PubMed | Google