Gouty Tophi

Abstract: 55 yo man with painful nodules on hands
History: This 55 yo laborer was seen for painful lesions of hands and associated arthritis. He was diagnosed with gout two years ago when he had an episode of podagra. Allopurinol causes an exacerbation of his pain, so he stopped taking it and maintains himself on colchicine 0.5 mg q.o.d. It is clear that he rarely sees his PCP. The patient has a history of kidney stones.
O/E: 8-10 mm in diameter nodules on some fingers. Fusiform deformities of a few fingers. Toes normal.
Clinical Photo(s):





Lab:
Histopathology: Biopsy pending. On punch biopsy the plug had a chalky look which I assume is uric acid crystals. Pathology confirms clinical impression. I will get a photomicrograph and insert it here.
Diagnosis or DDx: Tophaceous Gout
Questions: How can this man be helped?
Reason(s) Presented: For a discussion on treatment of tophaceous gout.
References:
1. eMedicine.com
2. Jelley MJ, Wortmann R.
Practical steps in the diagnosis and management of gout.
BioDrugs. 2000 Aug;14(2):99-107.
University of Oklahoma, Health Sciences Center, Tulsa Campus, Department of Internal Medicine, Tulsa, Oklahoma, USA.
One of the earliest described conditions, gout continues to plague humanity. It is characterised by the deposition of monosodium urate crystals in the joints and soft tissue. The main clinical features of gout are hyperuricaemia, acute monoarticular arthritis, tophi and chronic arthritis, along with nephrolithiasis. Gout typically occurs in middle age and more commonly in men. Asymptomatic hyperuricaemia does not require treatment. The initial attack of acute gout usually affects a single joint, often the first metatarsal phalangeal joint. Definitive diagnosis requires demonstration of urate crystals in the joint fluid. Treatment of acute gout includes nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids. The most important factor in success of treatment is how quickly therapy is begun after onset of symptoms. Drug treatment of hyperuricaemia includes allopurinol, sulfinpyrazone, probenecid and benzbromarone and should be used in patients with frequent gout attacks, tophi or urate nephropathy.