Chronic Tophaceous Gout With Unusual Large Tophi

Content

• Patient Cases
• What Are Gout Tophi? Heres What Causes Them And How To Treat Them
• How To Stop Gout
• Patient Data
• Are Tophi Painful?

It is important to note that usually gout tends to present as articular disease first, and cutaneous gout forming tophi usually correlate with chronicity and uncontrolled disease . Gout is a common disorder of uric acid metabolism, characterized by recurrent episodes of inflammatory arthritis, tophaceous soft tissue deposits of monosodium urate crystals, uric acid renal calculi and chronic nephropathy. We also emphasize the disabling effects of the under-treated hyperuremic arthropathy. Chronic injury to intra-articular cartilage leaves the joints more susceptible to subsequent joint infections. Untreated chronic tophaceous gout can lead to severe joint destruction and, rarely, renal impairment. Deposition of monosodium urate crystals in the kidney can result in inflammation and fibrosis, leading to reduced renal function or chronic nephropathy.

What foods are low in purines?

The following foods are low in purine.Eggs, nuts, and peanut butter.
Low-fat and fat free cheese and ice cream.
Skim or 1% milk.
Soup made without meat extract or broth.
Vegetables that are not on the medium-purine list below.
All fruit and fruit juices.
Bread, pasta, rice, cake, cornbread, and popcorn.

SnapshotA 55-year-old woman presents to the emergency department with acute pain in the left proximal interphalangeal joint of the second digit. She reports that the pain is excruciating and has happened once a few years ago but self-resolved over the course of 2 weeks. She states that she recently increased her alcohol and red meat consumption and was recently started on hydrochlorothiazide.

Patient Cases

The term “intratendinous infiltration” includes many aspects of the relationship between tophi and the tendon, as seen in reports that show that gout can affect the tendons through intratendinous infiltration causing compressive syndromes [12–14]. The term “infiltration” can encompass tophi within the tendon, those leading to extrinsic compression and those enveloping the tendon. In individuals with recurrent attacks of gouty arthritis physicians will prescribe medications to reduce blood uric acid levels . The goal of antihyperuricemic therapy is to reduce the frequency of attacks and dissolve tophi. Because acute CPPD disease closely resembles gout, the definitive diagnosis often requires synovial fluid analysis. Synovial fluid should be microscopically analyzed for cell count and crystal analysis under compensated polarizing microscopy.

What Are Gout Tophi? Heres What Causes Them And How To Treat Them

Many people will have another attack in the next 6 to 12 months. Gout may occur after taking medicines that interfere with the removal of uric acid from the body. People who take certain medicines, such as hydrochlorothiazide and other water pills, may have a higher level of uric acid in the blood.

None of the patient's joints were aspirated during her hospital stay. Because asymptomatic hyperuricemia usually does not lead to gout or other health problems, treatment to prevent a first attack of gout is generally inadvisable. In unusual circumstances, when very high uric acid levels threaten the kidney, treatment may be justified. This study showed the superiority of febuxostat to 300 mg of allopurinol and it emphasized the importance of titrating the dose to reach target levels instead of using a standard dose of 300 mg in all patients. Furthermore, after cessation of prophylaxis 8 weeks after starting febuxostat or allopurinol, the incidence of gout flares doubled in the group taking 120 mg of febuxostat and tripled in the group taking 80 mg of febuxostat and 300 mg of allopurinol.

These medicines can prevent attacks of gouty arthritis and prevent MSU crystals from being deposited in the tissues. Medicines that lower urate levels should not be started during an acute attack of gout; instead they should be started a few weeks after the attack has resolved. Long-term prophylaxis with urate lowering therapy is used to maintain serum urate levels below 6 mg/dL, while considering the individual needs of the patient. Xanthine oxidase inhibitors , uricosuric, and uricase agents are three classes of drugs approved for lowering urate levels to help prevent acute flares and development of tophi in patients with gout. We present a 47 year old man, complaining about the appearance of solid oval formations in the area of the elbows and right hand with about one year duration (fig. 1a-d). According to the anamnestic data, the patient had suffered from gouty tophi in the past and has been treated for gout, but at the time of the examination in the clinic he was completely asymptomatic.

Attacks typically last for hours and usually spontaneously resolve within 5-7 days. These attacks can be precipitated by alcohol, diuretics, trauma, purine-rich foods such as meat and shellfish, and drugs such as cyclosporine to name a few9. The crystals remain within the joint, however, predisposing to subsequent attacks due to chronic low grade inflammation10 during the intercritical phase of the disease. The management of gouty tophi has generally shifted from surgical excision to conservative therapy due to surgery’s traditional association with high wound complication rate. Yet there are still patients who are indicated for surgical excision of gouty tophi, including for functional or cosmetic reasons.

In this sense, a bone scan and a positron emission tomography-computed tomography (PET-CT) were negative for metastasis and malignancy. There was no family history consistent with an inherited defect that could lead to purine overproduction. 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. In our patient, renal function was deranged although a detailed evaluation could not be undertaken. A 40-year-old man presented with multiple nodules over bilateral hands, feet, elbows, knees and ankles since four years.

Patient Data

If the body is unable to eliminate large burdens of urate, hyperuricemia develops. As urate levels increase and saturate the synovial fluid or soft tissues, crystals precipitate, leading to tissue damage and the development of tophi. The accumulation of urate crystals in soft tissues and joints activates monocytes and macrophages to clear the crystals by phagocytosis. This leads to the release of proinflammatory cytokines and chemokines into the surrounding area, triggering a cascade of acute inflammatory reaction and influx of neutrophils into the joints, resulting in swelling of the joint or soft tissue. Acute gouty arthritis typically presents with a sudden and severe exquisitely painful joint, most classically in the first metatarsophalangeal joint . Demonstrating the presence of monosodium urate crystals in the joint fluid or tophus has been the gold standard for the diagnosis of gout.

Nonsteroidal anti-inflammatory drugs , such as naproxen sodium or ibuprofen . These help relieve pain and inflammation caused by gout attacks and joint damage from tophi. Tophi can be aspirated or the tophaceous material expressed and examined under polarize microscopy as well to confirm a diagnosis of chronic tophaceous gout. Severe tophaceous gout is associated with renal impairment, alcohol, obesity, diet, hypertension, family history, and low socioeconomic status1,2. Treatment failure is estimated in about 1% to 1.5% of cases of gout in the United States3.

Are Tophi Painful?

Thus, gentle and meticulous handling of soft tissue was essential for all cases and excessive undermining should be avoided as this would further impair the viability of the skin flap. Our preferred approach is a complete or near-complete excision of the gouty tophi. The rationale is based on our experience; we observed that delayed wound healing and wound complications often occur if we only remove a portion of the tophaceous material instead of the entire tophi in a region.

What is Tophaceous gout?

Tophaceous gout occurs when uric acid crystals form masses of white growths that develop around the joints and tissues that gout has affected. These masses, called tophi, are often visible under the skin and tend to look like swollen nodules.

An elevated SU level alone, however, does not serve as the sole criterion for gout. Although sustained hyperuricemia is a risk factor for acute gouty arthritis, tophaceous gout, and uric acid nephrolithiasis, most patients with hyperuricemia will never have an attack of gout. No treatment is required for asymptomatic patients, but it is prudent to determine the cause of hyperuricemia and correct it if possible. Since gout is a life-long disease, often requiring life-long therapy, the importance of a definitive diagnosis cannot be over-emphasized.

A synovial aspiration for microscopic analysis should be obtained whenever feasible and examined grossly for color and turbidity. In general, transparent synovial fluid in the syringe is more suggestive of a noninflammatory condition, whereas fluid that appears turbid or purulent is more suggestive of inflammation or infection . An additional proposed mechanism involves the role of an inflammasome and interleukin 1 (IL-1) in the pathogenesis of inflammation induced by MSU and CPPD .

Clinical Presentation

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