Chronic Tophaceous Gout Manifesting With Bilateral Diffuse Pedal Swelling

Content

• Allopurinol
• Patterns Of Opioid Prescribing For Ra Patients
• Therapy
• Clinical Presentation
• Why Tophi Develop And How To Remove Them
• When To Contact A Medical Professional

When you’re experiencing a flare-up, get treatment quickly to prevent permanent joint damage. Rest, avoid alcohol, cut back on animal proteins, and use an ice pack to cool and soothe the joint. Gout occurs when a substance called uric acid builds up in the blood. Uric acid forms naturally when our bodies break down purines, compounds found in our own tissues and in certain foods. Not everyone with elevated uric acid develops gout—more is involved.

Allopurinol

Frequently, uric acid tophi are present and contribute to bone and cartilage destruction. Tophi can be found around joints, in the olecranon bursa, or at the pinna of the ear. With treatment, tophi can be dissolved and will completely disappear over time. In this elderly lady with chronic tophaceous gout, significant renal impairment, and other comorbidities, we started urate lowering therapy with 80 mg of febuxostat q.d. Concomitantly, prophylactic medication for expected gout attacks was started with 10 mg of Prednisolon q.d., 0.5 mg of colchicine e.o.d. day, and low-dose ibuprofen as needed.

Two types of crystals — monosodium urate and calcium pyrophosphate dihydrate — are commonly involved in gout and CPPD disease, which are described in this chapter. Rigby and Wood9 compared the New York and Rome criteria in 59 patients with gout and 761 patients with other arthropathies. They found that the best individual criterion was 1 or more attacks of podagra . In contrast, the presence of a tophus was the least valuable criterion.

Patterns Of Opioid Prescribing For Ra Patients

LORI B. SIEGEL, M.D., is chief of rheumatology at the Finch University of Health Sciences, Chicago Medical School. She received her medical degree from the Medical College of Wisconsin, Milwaukee, and completed a residency in internal medicine and a fellowship in rheumatology at Georgetown University Hospital, Washington, D.C. Gouty tophi involving the proximal interphalangeal joint with erythema of the overlying skin. Note erythema and swelling of the first metatarsophalangeal joint.

Frequently clinical evaluation alone cannot fully explain the problems caused by tophi. We are proposing a classification of this relationship that is reliable and may be easily recognised. This may assist in the diagnosis and in the management of the treatment of patients with chronic tophaceous gout. Chronic gout and rheumatoid arthritis are common medical manifestations with debilitating effects on patients.

Diagnosis

Historically gout was divided into primary and secondary forms. Due to overlap in metabolic defects within the groups, a more accurate system has been derived characterizing gout into idiopathic, secondary, and drug-induced forms1. The causative factor in idiopathic gout is typically unknown (75-90 percent) but in most cases is felt to result from an unexplained impairment of uric acid excretion by the kidneys2. The remaining cases of idiopathic gout may occur due to an inborn error in purine metabolism involving its synthesis/overproduction, catabolism, or interconversion. Myeloproliferative disorders such as leukemia and lymphoma, chemotherapeutic agents, hemoglobinopathies, alcohol, chronic renal failure, dehydration, and diabetes have all been implicated in secondary gout.

On day 2 of admission, a gastroenterology consultation was obtained and an esophagogastroduodenoscopy was performed, which showed mild antral gastritis. The patient was administered pantoprazole sodium, 40 mg/d, for gastritis and severe anemia and to prevent gastrointestinal bleeding. The patient was also administered ceftriaxone sodium, 1 g/d, as empiric therapy as a result of the elevated white blood cell count and fever.

Tophi generally develop within affected joints, although the location may vary. Our patient was a case of chronic tophaceous gout 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. 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. Cutaneous tophi appear as cream colored to yellowish nodules, are firm and mobile with overlying skin often being thin and red.

However, these conditions are not typically identified concomitantly and can be hard to distinguish from one another. We report a rare case of a 50-year-old white woman with a history of chronic gout and rheumatoid arthritis who presented with intradermal tophaceous gout. Adverse effects include rash, precipitation of acute gouty arthritis, GI intolerance, and uric acid stones. Probenecid increases urinary calcium excretion in patients with gout and, thus, is contraindicated in patients with a history of calcium or urate nephrolithiasis. Drug interactions with probenecid include interference with penicillin and ampicillin excretion and autoimmune hemolytic anemia. Chronic tophaceous gout usually develops after 10 or more years of acute intermittent gout, although in rare cases, tophi may be the initial manifestation of the disease.19 Tophi appear as firm swellings.

Ten hours before seeking medical assistance, the tophus burst releasing a viscous, chalk-like material. Although parenteral ACTH is effective, it may require several repeat injections and cannot be used in patients with recent prior use of systemic steroids, since the action of ACTH requires an unsuppressed adrenal axis. ACTH has not been shown to be any more effective than systemic corticosteroids. In a study25 comparing single intramuscular doses of ACTH with triamcinolone acetonide for the treatment of acute gout, both treatments were found to be effective. Nine of 15 patients receiving ACTH required at least one repeat injection, compared with five of 16 patients receiving triamcinolone acetonide. Triamcinolone acetonide has also been shown to be as effective as indomethacin in relieving acute gouty arthritis.26 Triamcinolone acetonide is especially useful in patients with known contraindications to NSAIDs.

Can I remove Tophi myself?

Yes, tophi can be removed surgically. If they are infected (which is not common, but does occur), they can require drainage and antibiotics.

MR imaging of the thoracic spine demonstrated enhancement of the mass lesion within the spinal canal and within the posterior elements . PET/MR fusion showed hypermetabolic activity involving the T5–T7 posterior elements and adjacent soft tissues . A CT-guided percutaneous biopsy of the posterior elements of T6 was performed with sampling of the hypermetabolic tissue, which yielded soft cores of white and reddish-brown tissue that was interpreted by pathology as gouty tophi . The main purpose of this study was to develop a feasible classification system for tophi and their relationship with tendons.