The Reply

Abstract

We read with interest the Letter to the Editor by Konstantinos Parperis, MD about our report entitled “A Missed Opportunity: Tophaceous Gout,” in which we described the case of a 70-year-old Filipino man whose chronic tophaceous gout was initially misdiagnosed as rheumatoid factor (RF)-positive, erosive rheumatoid arthritis.1Gazitt T. Thomason J. Hughes G.C. A missed opportunity: tophaceous gout.Am J Med. 2015; 128: 571-573Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Relying on the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for rheumatoid arthritis2Aletaha D. Neogi T. Silman A.J. et al.2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.Ann Rheum Dis. 2010; 69: 1580-1588Crossref PubMed Scopus (2488) Google Scholar and the patient's favorable response to interleukin-1 blockade, Parperis contends that our patient actually has 2 conditions, gout and rheumatoid arthritis. While co-existent gout and rheumatoid arthritis has rarely been reported,3Kuo C.F. Tsai W.P. Liou L.B. Rare copresent rheumatoid arthritis and gout: comparison with pure rheumatoid arthritis and a literature review.Clin Rheumatol. 2008; 27: 231-235Crossref PubMed Scopus (22) Google Scholar and certain features of the case are consistent with both diseases, we maintain that our patient's erosive arthritis is more likely explained by gout alone rather than gout and rheumatoid arthritis. First, the 2010 ACR/EULAR Classification Criteria for rheumatoid arthritis exclude patients with synovitis “better explained by another disease,” such as gout or psoriatic arthritis; thus, in this case, use of these classification criteria to diagnose rheumatoid arthritis is not appropriate. Second, the episodic and asymmetric pattern of arthritis did not suggest underlying rheumatoid arthritis, which is persistent and highly symmetric. Third, as we mentioned in the original case description, the presence of serum RF is observed in a variety of inflammatory conditions other than rheumatoid arthritis, including gout; and among gout patients, serum RF may be more common in those with tophaceous disease.4Kozin F. McCarty D.J. Rheumatoid factors in the serum of gouty patients.Arthritis Rheum. 1977; 20: 1559-1560Crossref PubMed Scopus (20) Google Scholar, 5Gigante D. Giacomello A. Rheumatoid factors in the serum of gouty patients.Arthritis Rheum. 1980; 23: 379-380Crossref PubMed Scopus (4) Google Scholar Finally, the patient's second, acute presentation with polyarthritis occurred after initiation of methotrexate, which is not at all consistent with a diagnosis of rheumatoid arthritis. Thus, while it is conceivable that our patient has gout and rheumatoid arthritis, we maintain that his current presentation is adequately explained by gout alone. A Missed Opportunity: Tophaceous GoutThe American Journal of MedicineVol. 129Issue 1PreviewI read with great interest the case study by Gazitt et al,1 “A Missed Opportunity: Tophaceous Gout,” published in The American Journal of Medicine. Full-Text PDF