Chronic tophaceous gout

Abstract

Forty-three-year old male, consumer of 2 litres (80 ounces) of beer every day for the past 21 years. Fifteen years ago, he presented acute pain along with monoarticular inflammation of the lower limbs. At first he presented 2-3 annual episodes of monoarthritis, which improved with non-steroidal anti-inflammatory drugs. The patient did not follow the pharmaceutical treatment or the hygienic-dietetic measures recommended by his general practitioner correctly, so his monoarthritic crises became more frequent, extending to affectation of upper limb joints; the clinical picture evolved to oligoarthritis and finally to polyarthritis. He currently attended consultation due to worsening of inflammatory arthralgias in the hands and feet, along with deformity, which made daily activities difficult. Physical exploration highlighted the presence of tophi at the level of the elbows, feet, and hands, some of them complicated with fistula to the exterior (Figures 1A and 1B), where the presence of monosodium urate crystals was observed. Laboratory tests detected uricemia a level of 8.3, with the rest of basic biochemistry at normal levels. Tests for blood count, acute phase reactants, rheumatoid factor, and citrullinated antibodies were normal or negative. Bone X-rays of the hands and feet showed increased soft tissue, along with the presence of significant bone erosion with sclerotic margins, highlighting a small, thin calcified line,1 characteristic of gouty arthropathy (Figures 2A and 2B).