Msk Dermatology · Year 2 · from Msk Dermatology
Case 2: Chronic Tophaceous Gout
Patient Presentation
Demographics: 68-year-old man
Chief Complaint: "I have painful bumps on my fingers and my joints hurt all the time."
History of Present Illness: The patient has a 20-year history of gout with numerous acute flares, initially affecting his feet but now involving multiple joints. He has been non-compliant with urate-lowering therapy, stopping and starting allopurinol multiple times due to flares when initiating treatment. Over the past 5 years, he has developed visible lumps on his fingers, elbows, and ears. He now experiences constant low-grade joint pain with superimposed acute flares every few weeks. His most recent flare began 4 days ago affecting his right wrist.
Past Medical History:
- Gout for 20 years
- Chronic kidney disease stage 3b (eGFR 38 mL/min)
- Hypertension
- Type 2 diabetes mellitus
- Congestive heart failure (EF 40%)
Medications:
- Allopurinol 100 mg daily (restarted 1 month ago)
- Furosemide 40 mg daily
- Carvedilol 12.5 mg twice daily
- Lisinopril 20 mg daily
- Metformin 500 mg twice daily
- Aspirin 81 mg daily
Physical Examination
- Vital Signs: BP 142/88 mmHg, HR 72 bpm, BMI 30 kg/m2
- Hands:
- Multiple firm, irregular nodules (tophi) over DIP joints, PIP joints
- White chalky material visible through skin at some sites
- Right wrist: actively inflamed with warmth, swelling, tenderness
- Chronic deformity of multiple finger joints
- Elbows: Large olecranon tophi bilaterally
- Ears: Tophi visible on helices bilaterally
- Feet: Chronic deformity of first MTP joints with overlying tophi
Workup and Results
Laboratory Studies:
| Test | Result | Reference Range |
|---|---|---|
| Serum Uric Acid | 10.8 mg/dL | 3.5-7.2 mg/dL (elevated) |
| Creatinine | 1.9 mg/dL | 0.7-1.3 mg/dL |
| eGFR | 38 mL/min | >90 mL/min |
| ESR | 48 mm/hr | 0-15 mm/hr |
Imaging:
- Hand radiographs:
- Asymmetric soft tissue masses (tophi)
- Punched-out erosions with overhanging edges ("rat bite" erosions, Martel sign)
- Relative preservation of joint space in early erosive areas
- No osteopenia
- Dual-energy CT: Extensive urate deposition in hands, wrists, feet, elbows
Clinical Image
Polarized light microscopy of synovial fluid showing needle-shaped, negatively birefringent monosodium urate crystals within neutrophils, diagnostic of gout. The crystals appear yellow when parallel to the axis of the red compensator. Source: Wikimedia Commons, Public Domain.
Diagnosis
Chronic Tophaceous Gout with Acute Flare
Features:
- Visible tophi at multiple sites
- Chronic gouty arthropathy with erosions
- Ongoing hyperuricemia despite low-dose allopurinol
- Active flare superimposed on chronic disease
- Multiple comorbidities complicating treatment
Treatment Plan
Acute Flare Management:
- Prednisone: 30 mg daily for 5 days then stop (NSAIDs contraindicated due to CKD and heart failure; colchicine requires dose reduction and caution)
- Consider intra-articular injection of wrist with triamcinolone if accessible
Urate-Lowering Therapy Optimization:
- Continue allopurinol and titrate: Currently 100 mg; increase gradually by 100 mg every 2-4 weeks
- Target: Serum uric acid <5 mg/dL (lower target for tophaceous gout)
- May need doses up to 300-400 mg despite CKD (dose can exceed GFR-based limits if tolerated and monitored)
- Prophylaxis: Low-dose colchicine 0.3 mg daily (reduced dose for CKD) during ULT titration
Monitoring:
- Serum uric acid monthly during titration
- Renal function, CBC every 2-4 weeks during allopurinol titration
- Watch for hypersensitivity reaction signs
If Refractory:
- Consider pegloticase if fails conventional ULT (requires infusion center, risk of immunogenicity)
- Urology referral for nephrolithiasis assessment
Teaching Points
- Tophaceous gout: Develops after years of inadequately controlled hyperuricemia; represents massive urate burden
- Target uric acid <5 mg/dL: Lower target for tophaceous gout to promote tophus dissolution; below saturation point allows crystals to dissolve
- Allopurinol dosing in CKD: Can exceed traditional GFR-based dose limits with careful monitoring; achieving target uric acid more important than arbitrary dose ceiling
- Radiographic findings: "Punched-out" erosions with overhanging edges (Martel sign), preserved joint space initially, asymmetric soft tissue masses - classic for gout
- Treatment challenges: Multiple comorbidities (CKD, CHF) limit NSAID use; colchicine requires dose adjustment; glucocorticoids often necessary