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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
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.
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.
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.
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.
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.
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.
The early treatment of gout is warranted to avoid the
further complications of gout-like chronic tophi causing new joint deformities.
Pan Afr Med J. 2015; 22: 132.
Chronic tophaceous gout with unusual large tophi: case report
Nassira Aradoini et al.
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