New Onset of Very Large Tophi in a Patient After Kidney Transplantation

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A woman, aged 54 years, presented to our hospital with a one-month history of painful swelling of the joints of her hands and feet, that had begun gradually over a 3-year period with no prior medical history of gouty disease. She had undergone kidney transplantation 12 years earlier and was treated with immunosuppressive medications (cyclosporine, prednisolone, and mycophenolate mofetil). Upon physical examination, she had limitation in flexion movements of the distal and proximal interphalangeal joints of both hands, and she could not bear weight due to large and painful tophi on both feet. The swollen tender joints included the distal and proximal interphalangeal joints of both hands (figure 1A▶), the first metatarsophalangeal joint in the right foot (figure 1B▶), and the first and second metatarsophalangeal joints, the transverse tarsal joint and second proximal interphalangeal joint in the left foot (figure 1C▶). Serum creatinine and uric acid levels were elevated (creatinine=1.9 mg/dL; uric acid=10.4 mg/dL), but creatinine clearance was decreased (40.2 mL/min). A plain-film radiograph revealed extensive juxta-articular erosions with soft tissue swelling and little osteoporosis. Compensated polarized light microscopy of the lesions revealed needle-shaped, negatively birefringent urate crystals, compatible with gouty tophi. The patient was treated with celecoxib (100 mg every 12 hours), and her dose of prednisolone was increased (1 mg/kg per day). After three days she experience relief of the joint pain. On day 5, celecoxib was discontinued, and prednisolone was tapered over a 14-day period to a maintenance dose (0.1 mg/kg per day). She was started on an escalating dose of allopurinol, beginning with 100 mg per day until reaching 300 mg per day. By the 6-month follow-up, she had not experienced another acute attack, and the size of the tophi had significantly decreased. Figure 1. Multiple subcutaneous tophi are seen in the hands (A) and large tophi in the feet (B, C).