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Tophi: A pointer towards the diagnosis of gout Jency Maria Koshy, Mary John, Rupinder Kaur1, Lydia Solomon Departments of Medicine and 1Pathology, Christian Medical College, Ludhiana, Punjab, India
A B S T R A C T Tophi are deposits of monosodium crystals in people with long-standing gout. We report a case of a 34-year-old male presenting with joint pains and soft yellowish swelling over the web spaces of the toes. Aspiration of the same revealed monosodium crystals leading to a diagnosis of Tophaceous gout. Keywords: Gout, monosodium crystals, tophi
A 34-year-old male presented with joint pains for two years worsening over six months prior to the presentation. The sequence of involvement was small joints of hands followed by wrist, elbow, and both shoulders with a history of morning stiffness. Examination revealed dactylitis of middle and ring finger bilaterally. Soft yellowish fluctuant swellings were noted in the web spaces of first and second toes of the right foot [Figure 1] and the dorsal aspect of the left third toe [Figure 2]. Aspirate revealed bright needle-like negatively birefringent monosodium urate crystals under polarized microscope and on Gram stain [Figures 3 and 4] leading to a diagnosis of Tophaceous gout. Abnormal laboratory investigations included 2 mg/dl serum creatinine, 8.5 g/dl hemoglobin, 15, 200/mm3 total leukocyte count, and 11.7 mg/dl serum uric acid. Fractional excretion of uric acid was 1.08 (>0.7) suggesting an overproducer. Abdominal ultrasonography revealed nephrolithiasis. He was managed with analgesics during the acute phase and was initiated on the xanthine inhibitor, allopurinol on follow up.
Figure 1: Yellowish fluctuant swelling in the web spaces of first and second toes of the right foot
Access this article online Quick Response Code: Website: www.cjhr.org DOI: 10.4103/2348-3334.134283 Figure 2: Soft swelling in the dorsal aspect of the left third toe
Corresponding Author: Dr. Jency Maria Koshy, Department of Medicine, Christian Medical College, Ludhiana, Punjab - 141 008, India. E-mail:
[email protected]
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Koshy, et al.: Tophaceous gout
Figure 3: Field packed with bright needle like negatively birefringent monosodium urate crystals under polarized microscope
DISCUSSION
REFERENCES 1.
Tophi are deposits of monosodium crystals in people with long-standing gout. Decreased creatinine clearance in gout is associated with early presentation with tophi.[1] The tophaceous deposits accumulate around the joints of the feet, fingers, joints, elbows, Achilles’ tendon, pinna of the ear, within olecranon bursa, or prepatellar bursa. Chronic tophaceous gout can mimic chronic rheumatoid arthritis with rheumatoid nodules.[2] Other differentials to be considered are rheumatoid nodules, nodal osteoarthritis, psoriatic arthritis, or scleroderma. Persistently high uric acid level can lead to urolithiasis or urate nephropathy,[3] as in this case.
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Figure 4: Gram staining depicting monosodium crystals
2. 3
Dalbeth N, House ME, Horne A, Taylor WJ. Reduced creatinine clearance is associated with early development of subcutaneous tophi in people with gout. BMC Musculoskelet Disord 2013;14:363. Rott KT, Agudelo CA. Gout. JAMA 2003;289:2857-60. Philip J. Crystal induced arthropathies. In: Pispathi K, editor. Manual of Rheumatology. 2nd ed. Mumbai: Indian Rheumatology Assoc; 2002. p. 130-50.
Cite this article as: Koshy JM, John M, Kaur R, Solomon L. Tophi: A pointer towards the diagnosis of gout. CHRISMED J Health Res 2014;1:128-9. Source of Support: Nil. Conflict of Interest: No.
CHRISMED Journal of Health and Research /Vol 1/Issue 2/Apr-Jun 2014
