A Rare Case Of Ulcerated Tophaceous Gout

Content

• What Are Kidney Stones? Symptoms, Causes, Diagnosis, Treatment, And Prevention
• Gout And Calcium Pyrophosphate Deposition Disease
• Treatment
• Massive Gouty Tophi Presenting As Pseudotumor Of The Elbow: A Rare Presentation
• Diagnostic Dilemmas In Psoriatic Arthritis

Gout is a form of arthritis, hence it causes pain and discomfort in the joints. A typical gout attack is characterized by the sudden onset of severe pain, swelling, warmth, and redness of a joint. The clinical presentation of acute gouty arthritis is not subtle with very few mimics other than a bacterial infection. This condition can lead to significant debilitation in patients if not identified early and managed appropriately.3 Although both gout and RA are commonly observed in the general population, they rarely coexist in the same patient. With chronic elevated uric acid levels, the mono-sodium urate crystals may form painless deposits under the skin.

What Are Kidney Stones? Symptoms, Causes, Diagnosis, Treatment, And Prevention

Patients with tophaceous gout rarely develop ulcers, but when they do occur, these ulcers can be difficult to treat. This case study explores the diagnosis of and treatment options for patients with ulcerated tophaceous gout. The physical therapist should be aware that any patient with a history of gout, hyperuricemia, and/or a septic joint presentation should be refered for medical evaluation prior to treatment.

Drug treatments for acute attacks of gout are aimed at relieving pain and reducing inflammation. A thorough medical history and physical examination can reveal a number of significant indicators to help confirm or rule out gout. Of these, include the joints affected (ie. the big toe) as well as the speed of onset of the arthritis. More than 99% of primary gout cases are referred to as idiopathic, meaning that the cause of the hyperuricemia cannot be determined. They are most likely due to a combination of hormonal and genetic factors that cause metabolic abnormalities resulting in excess uric acid. The remaining 1% of primary gout cases are traceable to either of two rare inherited enzyme defects that affect purine synthesis in the cells.

Gout And Calcium Pyrophosphate Deposition Disease

Most of the differential diagnosis factors with gout can be considered here. Infection is always a major differential, especially in the patient presenting with new acute monoarticular arthritis. In addition, septic arthritis can coexist in a joint that has been or is involved in an acute CPPD disease attack as with gout. Thus, it is important to aspirate the involved joint whenever possible for microscopic examination of the synovial fluid and Gram stain and culture. Other differentials include trauma, bleeding, and other crystal-deposit diseases.

How do you stop gout from getting worse?

Take Care of Yourself 1. Get regular exercise and stay at a healthy weight. If you're overweight or obese, your body has more uric acid.
2. Get other health conditions under control.
3. Ask your doctor if you need to make changes to the medications you take.
4. Drink more fluids.

Tophi generally start to develop in the joints and tissues in the advanced chronic tophaceous stage. This occurs an average of 11.6 years after an initial attack of gout and is characteristic of gout that has gone untreated for long periods of time. Gout is a disorder of uric acid metabolism that causes deposition of Monosodium Urate crystals in joint spaces, which, in turn, elicit an acute inflammatory reaction. If the disease is refractory to monotherapy with either of XOI option, then a uricosuric agent can be added to an XOI as a second-line approach.15 Uricosuric drugs block renal tubular urate reabsorption. These drugs can be used in patients with under excretion of urate, but are generally not recommended in patients with advanced kidney disease. The two cases and our literature review try to emphasize the many faces of chronic gout, in particular, its presentation without previous gout attacks.

His condition worsened, and the numbness in his right hand became significantly aggravated over the previous three months before seeking treatment at our department. Hematological investigations revealed raised serum uric acid level (11 mg/dl), erythrocyte sedimentation rate of 38 mm/hour for the first hour and highly sensitive C-reactive protein level of 44.92 mg/l. Radiographs of the left elbow showed a huge soft tissue shadow with calcification . When you have chronic gout, you have swelling in your joints regularly.

Zonana-Nacach A, Alarcón GS, Daniel WW. Rheumatoid arthritis preceding the onset of polyarticular tophaceous gout . Allopurinol – Inhibits uric acid production and is useful for those who overproduce uric acid, who have kidney disorders, or who have kidney stones. The risk factors for gout, of which there are several, are identical to those for hyperuricemia. One patient developed wound infection over his left 1st metatarsal-phalangeal joint 2 weeks post-excision of bilateral 1st meta-tarsal phalangeal joint tophi.

Tophi forming in the carpal canal can compress the median nerve, leading to CTS. Here, we describe a 25-year-old male with a family history of tophaceous gout who presented with typical CTS symptoms. Although he had chronic numbness in his right hand, he failed to present with any obvious palpable masses on his forearm or hand.

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. Some patients only experience acute gout attacks which may be limited to 1-2 times per year (or even 1-2 times in lifetime). However, for some patients, gout can be a chronic, relapsing problem with multiple severe attacks that occur at short intervals and without complete resolution of inflammation between attacks. This form of gout, called chronic gout, can cause significant joint destruction and deformity and may be confused with other forms of chronic inflammatory arthritis such as rheumatoid arthritis.

Treatment

Radiographic scans of the patient's feet also uncovered symmetric joint space narrowing with osteopenia . A wet mount specimen with polarized light microscopy of the punch biopsy for an abdominal skin lesion revealed monosodium urate crystals, which are indicative of tophaceous gout . Radiographic changes in gout are typically not present for 6-8 years. During the acute phase of the disease, only asymmetric soft tissue swelling may be present around the affected joint on imaging studies. With resolution of the inflammation, there is reversion back to normal with no evidence of disease on plain films. Recently, however, new evidence supports the use of more advanced techniques such as MRI during the intercritical period between attacks.

In general, gout includes joint swelling in both the lower and upper extremities. Inflammation in the first metatarsophalangeal joints is termed podagra, and it is highly suggestive of gout; however, any joint in the feet, ankles, knees, hands, wrists, or elbows may be involved. Acute gout can occur in the bursae, such as the olecranon or prepatellar bursae, where it causes bursitis, and can also occur in tendons such as the Achilles tendon and other soft tissue.

High levels of uric acid in the blood are associated with increased risk of kidney disease. Studies are being done to find out whether lowering uric acid reduces the risk for kidney disease. “As was illustrated in our patient, tophaceous ulcers are not only difficult to treat, but are also extremely debilitating. Our patient has chronic pain requiring opiate medications, decreased functionality of his limb and diminished sensation in this area,” the authors wrote. The authors suggest that in addition to finding better ways to manage severe tophaceous gout and renal failure, more research should be aimed towards better identification, diagnosis and treatment.

Massive Gouty Tophi Presenting As Pseudotumor Of The Elbow: A Rare Presentation

Occasionally, a gout attack triggers a systemic inflammatory response manifesting with fevers, leukocytosis, elevated sedimentation rates, and elevated C-reactive protein . Plain radiography, MRI, and scintigraphic findings on bone scan provide helpful diagnostic clues but are not useful in making a definite diagnosis of gout. Ultrasonography is a more reliable, noninvasive method for diagnosing gout.41 Ultrasonographic investigation can detect deposition of MSU crystals on cartilaginous surfaces, as well as tophaceous material and typical erosions.

Diagnostic Dilemmas In Psoriatic Arthritis

Cell count, Gram stain, and culture, in the right clinical setting, should be sought. Gout and CPPD disease are the most common of these disorders, but practitioners need to be aware of the presence of other types of crystal arthropathy, such as hydroxyapatite crystal deposition disease. In this case, crystals might not be seen on classic synovial analysis and some may require special staining. It is advisable to start probenecid at a low dose and increase the dose gradually until reaching the target serum urate level. The maintenance dose varies, averaging 500 to 1,000 mg 2 or 3 times a day.