Chronic Tophaceous Gout Research Articles

Surgical treatment of tophaceous gout in the extremities

Objective To review some clinical experiences during the treatment of patients with tophus in the extremities, with a focus on the techniques in surgical procedures. Methods From February 2009 to February 2016, a total of 149 patients with chronic tophaceous gout of the extremities underwent surgical treatment at our center. The patients were follow-up at 3 weeks, 6 weeks, 3 months and 6 months postoperatively to guide functional exercises. Results After the initial surgery, 84 patients were follow-up from 1.5 to 7.4 years, with a mean duration of 2.4 years. All the patients were satisfied with the appearance. The function had greatly been improved. Range of motion of the upper limbs was increased significantly and the joints of the lower limbs had no weight-bearing pain. Conclusion Surgical removal should be performed at once when there is joint stiffness to prevent the joint erosion. The incidence of acute attacks can be reduced and the systematic uric acid load can be reduced as well. The available surgical interventions are the most efficient approach to improve the appearance and joint function. Key words: Extremities; Surgical procedures,operative; Tophus

Experience with febuxostat in a patient with severe disabling gout

Gout is a chronic disease that frequently leads to disability if urate-lowering therapy is inefficient. The paper presents the positive experience with febuxostat, a novel non-purine xanthine oxidase inhibitor, in a young patient with disabling chronic tophaceous gout. Twelve-month therapy with daily 80-mg dose of febuxostat resulted in almost complete resorption of subcutaneous tophi and in a long-term lack of arthritis attacks with the persistent serum uric acid levels below target ones. This is the first experience in successfully switching from one to another xanthine oxidase inhibitor, which was described after febuxostat registration in the Russian Federation.

Lumps All Over: A Case of Chronic Tophaceous Gout (Harrison Syndrome).

Lumps All Over: A Case of Chronic Tophaceous Gout (Harrison Syndrome).

Chronic tophaceous gout with anti-CCP positivity: A rare presentation

Persistent gout may progress into a condition termed as chronic tophaceous gout, which involves the deposition of nodular mass of uric acid crystals called tophi in various soft tissue areas of the body. Generally, the anti-cyclic citrullinated peptide (anti-CCP) antibody testing is considered as a highly specific confirmatory test for RA. We present here a rare case report of chronic tophaceous gouty arthritis with anti-CCP positivity.

Surgical Management of Gout in the Foot and Ankle A Systematic Review.

The surgical management of tophaceous gout has been well documented in the literature, including its effect on foot pain and disability. To date, there have been no systematic reviews assessing the quality of the literature relating to the operative management of tophaceous gout and the outcomes in the foot and ankle. The following electronic databases were searched (1980-2014): Allied and Complementary Medicine, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Scopus, and the Cochrane Library. The articles identified were published in English and included adult participants (age ≥18 years) with diagnosed gout and surgical intervention to the foot and ankle. The Downs and Black Quality Index was modified to assess the quality of the articles being reviewed. Six articles were reviewed and were of moderate quality (mean quality score of 71%). Surgical management was conducted on men (88%) with a mean age of 52 years. There was wide variation in the types of surgical procedures performed, with 28% of studies reporting surgery to the first metatarsophalangeal joint. Most studies were retrospective. A wide range of outcome measures were reported: foot pain, function, preoperative and postoperative activity levels, monitoring of uric acid levels, and patient satisfaction after surgery. The review demonstrated a limited number of good-quality studies. Several surgical procedures for the foot and ankle in people with chronic tophaceous gout were reported. Future studies should include prospective observational studies using validated and reliable patient-reported outcome measures.

Tophaceous gout in thalassemia intermedia: a rare association.

A 32-year-old male presented with progressive swelling of fingers of both hands and joint pains. On physical examination, the patient had severe pallor, frontal bossing, zygomatic prominence, malocclusion of teeth and tophaceous deposits at knuckles and pinna (Fig. 1a). There was mild hepatomegaly and massive splenomegaly. On investigation, his hemoglobin was 6.1 g/dl (normal levels 13–17 g/dl), and he had microcytic normochromic anemia. He also had elevated uric acid levels of 14 mg/dl (normal levels 3.5–7 mg/dl) suggesting a hypermetabolic state. Chest and skull radiograph showed extramedullary hematopoiesis; skull radiograph revealed sun-ray appearance. Plain radiograph of the hands showed erosion of few phalanges, soft tissue swelling and ‘punched-out’ lytic lesions with sclerotic margins and overhanging bony edges (Martel's sign) [1] (Fig. 1b). Joint fluid aspiration revealed needle-shaped birefringent monosodium urate crystals. A genotypic diagnosis of double heterozygous thalassemia with hemoglobin E trait and phenotypic diagnosis of thalassemia intermedia with secondary chronic tophaceous gout was made. Crystal proven gout in a patient with thalassemia intermedia is a rare but important association. Figure 1: (a) Tophaceous deposits at pinna and (b) Martel's sign.

Dual-Energy Computed Tomography of the Knee, Ankle, and Foot: Noninvasive Diagnosis of Gout and Quantification of Monosodium Urate in Tendons and Ligaments.

Gout is a true crystal deposition arthropathy caused by the precipitation of monosodium urate into joints and periarticular soft tissues. It is the most common inflammatory arthropathy in men and women of older age with a male-to-female ratio of 3 to 8:1. The disease may progress from asymptomatic hyperuricemia through symptomatic acute gout attacks with asymptomatic periods into chronic symptomatic tophaceous gout. Although invasive arthrocentesis and demonstration of monosodium urate crystals on polarized light microscopy is definitive for the diagnosis of gout, dual-energy computed tomography (CT) allows for noninvasive visualization and reproducible volume quantification of monosodium urate crystals. Based on the high diagnostic performance, dual-energy CT has been included in the 2015 American College of Rheumatology/European League Against Rheumatism Collaborative Initiative Classification Criteria for Gout. Increasing evidence indicates the usefulness of dual-energy CT to guide the management of patients with suspected gout and monitor the effectiveness of urate-lowering medical therapy.

Assessment of cardiovascular risk from the use of an interleukin-1 inhibitor in patients with severe tophaceous gout

It is suggested that interleukin (IL)-1β inhibition may promote a reduction in the risk of cardiovascular diseases; however, the mechanism of this impact has not been adequately investigated. Objective: to evaluate the impact of canakinumab therapy on the structural and functional properties of the vascular bed and the stiffness of the vessel wall. Patients and methods. An open-labeled prospective study was conducted in 20 patients with chronic tophaceous gout at the V.A. Nasonova Research Institute of Rheumatology. Among the patients, there were 17 (85%) men and 3 (15%) women. All the patents received a single subcutaneous injection of canakinumab 150 mg. Estimation of high-sensitivity C-reactive protein (hs-CRP) and IL-6 levels, 24-hour blood pressure (BP) monitoring, duplex scanning of the carotid arteries (intimamedia thickness (IMT)), and determination of central artery stiffness (aortic pulse wave velocity (APWV), m/sec) were done before and 14 and 120 days after drug administration; the level of hs-CRP was quantitatively measured using a high-sensitivity immunoturbidimetric assay and the concentration of IL-6 was determined by xMAP technology (Human Grp I Cytokine 27-plex panel on a BioPlex-200 analyzer (Bio-Rad, USA). Antihypertensive lipidlowering therapy was not changed during the investigation. Statistical analysis was carried out using a package of applied Statistica 10.0 programs (StatSoft/Inc., USA). Results. Examination of the common carotid artery indicated that the median IMT that was 0.83 [0.71; 0.94] mm at baseline decreased to 0.74 [0.69; 0.84] mm by the end of the investigation (p = 0.022). The median APWV that was 14.12 [10; 17] m/sec at baseline dropped to 13.1 [11; 14] by the end of the investigation, but statistically insignificantly (p = 0.79). By the end of the investigation, there was a reduction in APWV as related to the baseline level in 13 (65%) patients: 7 of them had not one swollen joint and only 5 patients had a CRP level of > 5 mg/l, which was significantly less frequently than that in patients without positive changes in this index: in 6 (86%) of the 7 patients (p = 0.043). There was a direct correlation of changes in APW with those in serum CRP levels (p = 0.012 and p = 0.047, respectively) after 14 and 120 days and with those in serum IL-6 concentrations following 14 days (p = 0.003). 24-hour BP monitoring showed no significant BP change in the patients after 14 and 120 days after injection. The mean level of total cholesterol and triglycerides remained unchanged. Conclusion. The IL-6 inhibitor canakinumab can have a positive effect on IMT and arterial stiffness. The effect of the drug on the structural and functional properties of the vascular bed is due to the magnitude of its anti-inflammatory activity

Musculoskeletal ultrasonography in gout.

Gout is a frequent inflammatory disease induced by the deposition of monosodium urate crystals in joints and extra-articular tissues. The natural history of the disease includes four different phases: asymptomatic hyperuricemia, acute attacks, intercritical phase, and chronic tophaceous gout. Imaging techniques have several applications in the diagnosis, clinical monitoring and management of the disease but particularly, musculoskeletal ultrasound is able to detect a wide set of abnormalities in gout. This review reports the most relevant findings detectable by ultrasound and the current available data in the literature regarding the role of musculoskeletal ultrasound in gout..

Identification of vanishing tophi by three-dimensional dual-energy computed tomography in a patient with chronic tophaceous gout.

Large gout tophi are difficult to treat and sometimes needs operation for its elimination. Dual-energy computed tomography (DECT) is now being used for detection of tophi in patients with gouty arthritis. After intensive treatment, we could observe vanishing tophi with DECT.

The Human and Economic Burden of Difficult-to-Treat Gouty Arthritis

Gouty arthritis, one of the most painful and common forms of adult arthritis, is caused by monosodium urate crystal deposits in joints, most often in the lower extremities. Crystals trigger an inflammatory response leading to acute flares characterized by a rapid onset of pain, warmth, swelling, and redness in involved joints. Over time, continued monosodium urate crystal deposits and inflammation can lead to chronic tophaceous gout that result in bone erosion, progressing to joint destruction and significant disability. The goal of therapy in an acute gout flare is prompt and safe termination of pain and inflammation. Acute gouty arthritis is usually treated with nonsteroidal anti-inflammatory drugs, colchicine, or corticosteroids. However, for a growing number of patients, current standard treatments are ineffective or are contraindicated, largely due to the presence of comorbidities. Gouty arthritis can have a major negative impact of health-related quality of life, especially in patients with difficult-to-treat disease, as revealed by recent studies comparing health-related quality of life with that of the general population. Additionally, gouty arthritis also constitutes an important economic burden through absence from work and medical costs. This burden is even greater in patients with difficult-to-treat disease.

Value of procalcitonin measurement in the diagnosis of bacterial infections in patients with fever and flare of chronic gouty arthritis

We assessed serum procalcitonin (PCT) levels to distinguish bacterial infections from non-bacterial infections in patients with fever and flare of chronic gouty arthritis. One hundred febrile patients with chronic tophaceous gout flare-ups were collected consecutively between November 2011 and January 2014 from the Department of Rheumatology and Immunology, Sichuan Provincial People's Hospital. These patients were divided into non-infectious febrile group (68 patients) and bacterial infectious febrile group (32 patients, including 6 cases of pulmonary infection, 3 cases of infectious arthritis and 21 cases of skin infection, 2 patients died from severe infection were excluded), and 30 patients with flare of chronic gouty arthritis without fever and infection. Serum PCT, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), white blood cell (WBC) count and neutrophil ratio were determined. 57.3% (39/68) patients in the non-infectious febrile group had PCT levels ≥ 0.5 × 10³ ng/L and the ratio in the infectious febrile group was 66.7% (20/30) . No statistically significant difference was detected between them (P>0.05). 16.7% (5/30) patients had PCT levels ≥ 0.5 × 10³ ng/L in the afebrile group and both the differences between the afebrile group and the two febrile groups were significant (P<0.05). The differences of ESR, CRP, WBC count and neutrophil ratio between the two febrile groups were not statistically significant (P>0.05). In the chronic gouty arthritis patients with fever, the sensitivity and specificity of high PCT level (≥ 0.5 × 10³ ng/L) for detection of bacterial infections was 33.9% and 74.4%, the positive predictive value was 36.9% and the negative predictive value was 71.9%. The area under the curve (AUC) of PCT, CRP, ESR, WBC count and neutrophil ratio in patients with fever and chronic gouty arthritis was 0.598, 0.636, 0.612, 0.596 and 0.727, respectively. Serum PCT levels may be not a good marker for detection of bacterial infections in the patients with fever and flare of chronic gouty arthritis. Larger studies are needed to evaluate the value of PCT measurement in the patients with fever and flare of chronic gouty arthritis.

Febuxostat for the Treatment of Chronic Tophaceous Gout in a Patient on Continuous Ambulatory Peritoneal Dialysis

Hyperuricemic patients with gouty arthritis or tophi, a serum uric acid concentration of 8.0 mg/dL or higher, and complications should be treated with urate-lowering drugs. Conventionally, allopurinol is used to treat hyperuricemia and gout, but it is necessary to adjust the dosage according to the degree of renal impairment. Uncommonly, allopurinol may have severe or fatal side effects. The non-purine xanthine oxidase inhibitor febuxostat undergoes hepatic metabolism and may require less dose adjustment in association with renal function. It is considered to be an alternative treatment for hyperuricemic patients with chronic kidney disease. Our experience suggests that low-dose febuxostat is a promising alternative to allopurinol for the treatment of gouty arthritis or tophi in peritoneal dialysis patients. (Korean J Med 2015;89:229-232)

Clinical experience with the interleukin-1β blocker canakinumab in patients with chronic tophaceous gout: abolishment of arthritis and prevention of exacerbations when allopurinol is used

The interleukin (IL)-1β inhibitor canakinumab may be effective in relieving an acute gout attack and in preventing an arthritis exacerbation. However, there are insufficient data on the use of this agent to abolish and prevent arthritis in patients who are resistant to another anti-inflammatory therapy. Objective : to evaluate the efficacy of the interleukin (IL)-1β inhibitor canakinumab in patients with chronic tophaceous gout, who are resistant to traditional anti-inflammatory therapy, in order to abolish arthritis and to prevent its exacerbations when adjusting the optimal dose of allopurinol. Subjects and methods. An open-labeled prospective study was conducted in 20 patients (mean age, 54.5±12.7 years) with chronic tophaceous gout. Serum uric acid (UA) levels were 486.3±135.2 μmol/l. The inclusion criteria were crystal-verified gout; arthritis affecting more than 5 joints; inefficacy of non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GCs), or colchicine when used for over a month; more than 4 arthritis attacks during year. The exclusion criteria were Stage ≥3 chronic kidney disease, infectious diseases. All the patents received a single subcutaneous injection of canakinumab 150 mg. NSAIDs and/or colchicine was discontinued a day before the injection. The number of swollen and tender joints and visual analogue scale (VAS) pain intensity were estimated before and 14 and 120 days after the injection; SF-36v1 and HAQ changes were assessed before and 120 days after the injection. 14 days after the injection, all the patients were given allopurinol, the dosage of which was individually adjusted, by starting on 100 mg/day and subsequently increasing by 100 mg/day every 2 weeks (not more than 800 mg/day) until the goal UA level (<360 μmol/l) was reached. Results. 14 days after canakinumab injection, arthritis was abolished in 8 (40%) patients and 3 patients needed to continue NSAID therapy. Following 14 days of the injection, there was a decline in the number of swollen joints from 12 [5; 16] to 3 [0; 4] (р<0.001), that of tender joints from 10 [1; 25] to 4 [0; 15], VAS pain from 60 to 24 [10; 30] mm, and high-sensitivity serum C-reactive protein from 29 [1.8; 168] to 7.6 [0.2; 41] mg/l. After 120 days, the decline in the indicators remained in the majority of the patients; there were significant improvements in physical component summary (PCS) from 39±6.9 to 44.5±9.4 (р=0.04), mental component summary (MCS) from 52.6±7.6 to 55.6±8.2 (р=0.01); HAQ scores decreased from 1 [0.1; 1.5] to 0.7 [0; 0.9] (р=0.049). No attacks of arthritis were observed in 10 patients. Seven and 3 patients had 1 and 2 arthritis attacks, respectively. 17 (85%) patients achieved the goal serum UA level; the latter was <300 μmol/l in 12 (60%) patients. Median allopurinol dosage was 400 [300; 600] mg/day. By the completion of the study, 4 (20%) patients required continued NSAID therapy. Conclusion. The use of canakinumab in patients with severe gout, who are resistant to therapy with NSAIDs, colchicine, and GCs, is an effective method to treat arthritis and to prevent acute arthritis attacks during allopurinol therapy. The administration of high-dose allopurinol causes a target reduction in serum UA levels in most patents.

A Rare Cause of Knee Pain in Gout Patients: Tophi of Patella

Gout is a monosodium urate crystal deposit disease which generally occurs in middle-aged males and postmenopausal females. It is typically characterized by episodic acute and chronic arthritis, due to deposition of monosodium urate crystals in joints and connective tissue. Palpable deposits of crystals known as tophi may form particularly around joints but also elsewhere. Tophi can present as masses in many different body locations resulting in various clinical problems which are finally understood when the mass is sampled and analyzed. A 60-year-old male chronic tophaceous gout patient admitted to our hospital with complaints of bilateral patellar pain. After clinical, laboratory and radiological assessment, our diagnosis was consistent with patellar involvement of gouty tophi which is rarely seen. In this article, we present the clinical and radiological findings of a patient with bilateral severe patellar pain due to gouty tophi.

A Missed Opportunity: Tophaceous Gout

PRESENTATION The following case represents a missed opportunity to diagnosis chronic tophaceous gout. Several features of one patient’s case belied the original diagnosis. A 70-year-old Filipino man presented to the clinic, complaining of subacute worsening of chronic hand pain. Two weeks prior, he experienced increasing pain and swelling of the metacarpophalangeal joints and both wrists. Over the past several years, he had similar episodes, each lasting 2-3 weeks; shorter when he received oral nonsteroidal antiinflammatory drugs or prednisone. Between these periods, minimal joint swelling and stiffness remained. Nevertheless, over time, he noted progressive deformity of his metacarpophalangeal joints. In addition, he reported occasional pain during use of the left shoulder and both knees. He denied fever, chills, rash, or neurologic problems. He had a history of hypertension, chronic renal insufficiency, and remote heavy alcohol use. His only medications were naproxen and acetaminophen.

White Clay Drainage in Chronic Tophaceous Gout

Please cite this article as: Zapata Bonilla SA, Jaquez Nevarez MR, Lopez Reyes A, Rodriguez Henriquez P. Exudado en «arcilla blanca» en gota tofacea cronica. Reumatol Clin. 2015;11:328–329. ∗ Corresponding author. E-mail address: drszapatami@gmail.com (S.A. Zapata Bonilla). by destructive arthritis, often with degenerative changes, bone erosions and development of tophi. Acute attacks can become polyarticular, additive and ascending; with a tendency to increase in severity.3 Tophi area cardinal feature of this entity; their structure consists of a conglomerate of urate crystals surrounded by4 fibrosis and inflammatory tissue.

A Case of Triple Arthritis: Tuberculosis, MRSA and Gout in One Knee

Aim: To report a case of concurrent tuberculous and bacterial arthritis in chronic tophaceous gout. Presentation of the Case: A 59-year old Filipino male patient consulted for sensorial changes with four-month progressive swelling of the right knee draining non-foul smelling yellowish discharge with chalky material. He eventually had arthrocentesis of right knee. Blood cultures were all negative. Acid fast bacilli were present both in the synovial fluid and endotracheal aspirate. Endotracheal aspirate grew Mycobacterium tuberculosis. Synovial fluid grew methicillin-resistant Staphylococcus aureus (MRSA). He was treated with prednisone, clindamycin, colchicine, febuxostat, tramadol, and anti-tuberculous medications. He failed to undergo surgery. Patient eventually had fatal myocardial infarction. Discussion: To our knowledge, this is the first report of concurrent tuberculous and bacterial (MRSA) arthritis in gout. Case Study Tabula et al.; BJMMR, 8(8): 732-736, 2015; Article no.BJMMR.2015.499 733 Conclusion: This case highlights the possible differential diagnoses especially infections among patients with chronic tophaceous gout. Concurrent tuberculosis and bacterial arthritis can complicate the management of these patients. Hence, microbiologic and crystal analysis of synovial fluid is a very important part of the work-up to tailor the early, specific treatment for these patients.

Chronic Tophaceous Gout in Multiple Spines: A Case Report and Literature Review

Gout typically affects the 1st metatarsophalangeal joint. Spinal gout is rarely reported. Moreover, involvement of extensive spines is remarkably unusual. We describe a case of a 76-year-old woman with gout involving cervical, thoracic, and lumbar spines and sacroiliac joint. She presented with fever, severe back pain, and polyarthralgia and had multiple tophi on both elbows and the left 2nd and 5th proximal interphalangeal (PIP) joints. Monosodium urate crystals were confirmed from tophi on the left 5th PIP joint by polarized optical microscopy. Magnetic resonance imaging and computed tomography showed joint space narrowing and bony erosions on cervical, thoracic, and lumbar spines, and sacroiliac joint. Fever, back pain, and polyarthralgia improved significantly with oral steroid therapy. Spinal gout can involve multiple spines and other joints and it can be improved by medical treatment only. It should be considered in patients with uncontrolled gout who have acute severe back pain. (J Rheum Dis 2015;22:250-255)

Pandigital and subcutaneous chronic tophaceous gout with acute renal failure

Gout (Podagra) is a disorder of purine metabolism characterized by the deposition of monosodium urate crystals in joints and connective tissue and risk of deposition in kidney interstitium. Although acute gouty arthritis is familiar for most physicians, chronic gouty arthritis, which affects small joints of the hands can be difficult to distinguish from other common interphalangeal arthropathies such as rheumatoid arthritis (RA), psoriatic arthritis, and erosive osteoarthritis because of very similar presentations. Here we describe a 60-year-old male diabetic patient with pandigital, extensive subcutaneous tophaceous gout presented with uremic encephalopathy and joint deformities. He had been treated mistakenly as RA for 10 years.