Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor
2010:76:1;69-71
doi: 10.4103/0378-6323.58689
PMID: 20061741

Chronic tophaceous gout with severe deforming arthritis

Sujay Khandpur, Anil K.V Minz, Vinod K Sharma
 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Sujay Khandpur
Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi
India
How to cite this article:
Khandpur S, Minz AK, Sharma VK. Chronic tophaceous gout with severe deforming arthritis. Indian J Dermatol Venereol Leprol 2010;76:69-71
Copyright: (C)2010 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Gout is an inflammatory arthritis caused by cellular reaction to monosodium urate crystal deposition. Tophi are chalky, gritty accumulations of monosodium urate crystals that build up in soft tissue of an untreated gouty joint. Fortunately, advances in early diagnosis and treatment of gout have made such patients uncommon. We describe a dramatic clinical presentation of severe deforming arthritis due to chronic tophaceous gout. Such cases must be differentiated from other conditions manifesting as cutaneous nodules with crippling arthritis.

A 40-year-old man presented with multiple nodules over bilateral hands, feet, elbows, knees and ankles since four years. The lesions were initially small and painless that gradually increased in size, some of which ulcerated and discharged white chalky material. His past history was remarkable for bilateral, asymmetric, large (wrists, elbows, knees, ankles) and small joint (interphalangeal joints of hands and metacarpophalangeal and interphalangeal joints of feet) pain with swelling and erythema of 11 years duration. He had taken only traditional medications without relief. There was no family history of gout, or personal history of hypertension, alcohol use, and high purine diet intake. His occupation did not involve chronic exposure to chemicals, heavy metals or aerosols.

Dermatological examination revealed multiple, mobile, skin-to-yellowish colored, firm, dermal and subcutaneous nodules and large globose tumors, located on palms and dorsa of hands overlying interphalangeal joints, wrists, elbows, knees, ankles and interphalangeal joints of the feet [Figure - 1],[Figure - 2]. Some of the lesions ulcerated, discharging chalky material. The associated joints were deformed.

His hematological and biochemical examination revealed anemia (Hb-5.6 gm/dl), raised serum uric acid (11.4 mg/dl, normal - 2-7.4 mg/dl), blood urea (110 mg/dl, normal - 10-50 mg/dl) and serum creatinine (2.0 mg/dl, normal - 0.5-1.8 mg/dl). Liver function test, urinalysis and serum electrolytes were within normal limits. Rheumatoid factor was negative. Radiographic evaluation of both hands showed soft-tissue swelling and periarticular erosions in the lower end of radius and interphalangeal joints with sclerotic margins and overhanging edges. Polarizing microscopy of the chalky material from the ulcerated nodules revealed negatively birefringent needle-shaped urate crystals. Skin biopsy from the finger nodule revealed upper dermal perivascular chronic inflammatory cell infiltrate with amorphous eosinophilic material deposited in the reticular dermis. A diagnosis of tophi with gout was made. He was started on ultra low dose allopurinol (100 mg/day) and NSAIDs, but left against medical advice before a detailed nephrology work-up could be initiated.

Our patient was a case of chronic tophaceous gout (CTG) with severe disfiguring deformities and marked functional impairment. He presented for the first time to the dermatology OPD in view of multiple cutaneous nodules overlying joints and tendons on the hands, feet, elbows and knees. CTG usually manifests between 3-42 years (average 12 years) of initial untreated disease, due to accumulation of monosodium urate crystals around the joints (bursae, ligaments and tendons) especially the olecranon bursa, infrapatellar and Achilles′ tendons and subcutaneous tissue on the extensors of extremities including wrists and hands. [1] They may also involve ear helix, nasal cartilage, eyelids, cornea, tricuspid and mitral valves. Some unusual presentations include erosive intraspinal and paravertebral lesions and carpal tunnel syndrome. [2] Cutaneous tophi appear as cream colored to yellowish nodules, are firm and mobile with overlying skin often being thin and red. Bullous tophi have also been reported. [3] Risk factors include chronic diuretic therapy, excessive alcohol consumption, chronic use of cyclosporine, postmenopausal age group and the inability to take hypouricemic drugs due to allergy or renal disease. Our patient had only taken traditional medicines for joint pains and did not resort to specific therapy for gout. The long-term neglect of the condition by the patient led to deterioration with tophi deposition in the joints.

This condition has several mimickers which include histiocytic, rheumatological, infective, immunological and storage disorders. [4],[5] It must be differentiated from multicentric reticulohistiocytosis, which is characterized by deeply set, reddish-brown, non tender, small firm papules and nodules on the face (′coral beads′ and vermicular lesions bordering the nostrils, ears and retroauricular region, eyelids), forearms, elbows and hands with progressive, bilateral, asymmetric, erosive polyarthropathy with interphalangeal joint predominance, minimal or absent periosteal reaction and mild osteoporosis compared to the severity of erosions. Histology shows histiocytes and multinucleate giant cells with ′ground glass′ cytoplasm throughout the dermis. Rheumatoid nodule occurs in 25% cases of active RA in subcutaneous location, bursa and tendon sheaths over pressure sites such as olecranon process, extensors of forearms, hands and Achilles′ tendons. Nodal generalized osteoarthritis occurs in menopausal women and shows multiple Heberden′s nodules in distal interphalangeal joints and Bouchard′s nodules in proximal interphalangeal joints with associated osteoarthritis.

Pseudorheumatoid nodule is a juxta-articular form of nodular granuloma annulare with persistent nodules located in the small joints of the hands. Fibroblastic rheumatism is characterized by firm papules in the periungual area, hands and feet with associated polyarthritis. The nodules show dermal fibrosis interspersed with lympho-histiocytes. Tuberotendinous xanthomas present as multiple, grouped, yellowish brown nodules bilaterally on the trunk, knees, elbows, palms, soles, and dorsa of interphalangeal joints with raised triglyceride and cholesterol levels. Histopathology reveals many Touton giant cells and numerous foam cells in the dermis. Juvenile hyaline fibromatosis is an autosomal recessive mesenchymal dysplasia presenting as multiple subcutaneous tumors with flexion contractures of joints and radiolucent bone destruction. The lesions show amorphous hyaline material deposition in the extracellular spaces of the dermis and soft tissue.

Other uncommon differential diagnosis include mucinous nodules overlying rheumatoid arthritic joints, accelerated rheumatoid nodulosis secondary to methotrexate therapy, synovial cysts over tendon sheaths and bursae, tenosynovial nodules associated with Human T lymphotropic virus-1, sarcoidosis, subcutaneous and tendinous nodules in scleroderma and rarely angioimmunoblastic t-cell lymphoma with arthritis.

In our patient, the clinical features supplemented by characteristic laboratory and radiological findings helped in confirming the diagnosis. Complications of gout include renal involvement such as nephrolithiasis or acute and chronic gouty nephropathy. [1] In our patient, renal function was deranged although a detailed evaluation could not be undertaken.

Treatment of CTG includes diet modification, medical and surgical therapy. [1] Medical treatment includes NSAIDs, hypouricemic drugs like allopurinol and uricosuric drugs like probenecid and sulfinpyrazone. Surgery is usually avoided unless tophi are in a critical location, drain chronically or there is intractable joint pain, loss of motion and massive joint destruction. The conventional enucleating procedure may lead to complications such as skin necrosis, tendon or joint exposure. A ′shaver technique′ for deformity management of CTG has been described. [6]

References
1.
Kelley WN, Schumacher HR Jr. Crystal-associated synovitis. In: Kelley WN, editor. Textbook of rheumatology. 4 th ed. Philadelphia: Saunders; 1993. p. 291-336.
[Google Scholar]
2.
Bejer CP, Hartmann A, Woertgen C, Brawanski A, Rothoerl RD. A large, erosive intraspinal and paravertebral gout tophus: Case report. J Neurosurg Spine 2005;3:485-7.
[Google Scholar]
3.
Schumacher HR. Bullous tophi in gout. Ann Rheum Dis 1977;36:91-3.
[Google Scholar]
4.
Luz FB, Gaspar TAP, Kalil-Gaspar N, Ramos-e-Silva M. Multicentric reticulohistiocytosis. J Eur Acad Dermatol Venereol 2001;5:524-31.
[Google Scholar]
5.
Sayah A, English JC 3rd. Rheumatoid arthritis: A review of the cutaneous manifestations. J Am Acad Dermatol 2005;53:191-209.
[Google Scholar]
6.
Lee SS, Lin SD, Lai CS, Lin TM, Chang KP, Yang YL. The soft-tissue shaving procedure for deformity management of chronic tophaceous gout. Ann Plast Surg 2003;51:372-5.
[Google Scholar]

Fulltext Views
399

PDF downloads
85
Show Sections