Cutaneous Dissemination of Tophi Indicating Poorly Managed Gout: A Case Report
Abstract
Gout is a systemic metabolic disease caused by chronic hyperuricemia. Poor adherence to urate-lowering therapy is a major contributor to chronic gout. Disseminated cutaneous tophi are rare manifestations of tophaceous gout. We report the case of a 72-year-old man with chronic gout, presenting with multiple disseminated tophi, destructive polyarthritis and renal failure.
A 72-year-old man was hospitalized due to severe disabling pain in both ankles and heels, leading to an inability to walk. His BMI was 30 kg/m². Joint examination revealed ankle arthritis and mild flexion contractures affecting the hands, elbows and knees. Cutaneous manifestations included surgical scars on the fingers; large, firm, painless subcutaneous swellings on the second left finger, left elbow and along the postero-external aspect of the left forearm; diffuse infiltrated yellowish nodules, some ulcerated, on the legs, the left auricle and the third left finger. Biological tests showed metabolic syndrome with uncontrolled diabetes, mixed dyslipidemia and an elevated serum uric acid level of 530 µmol/L. He also presented with severe renal insufficiency and an elevated CRP level of 100 mg/L. Cutaneous biopsies from different sites revealed monosodium urate crystals, confirming the diagnosis of diffuse cutaneous tophi. Conventional radiographs of the hands and feet showed signs of gouty arthropathy. The patient was treated with colchicine (0.5 mg/day), prednisolone (30 mg/day for 3 days), atorvastatin, ramipril and insulin glargine (8 IU in the evening), resulting in favorable clinical improvement.
Keywords: Chronic gout; Tophi; Medication adherence; Renal insufficiency
Introduction
Gout is an ancient
systemic metabolic disease caused by chronic hyperuricemia, leading to the
deposition of monosodium urate crystals in joints and soft tissues1. Despite the proven efficacy of
urate-lowering medications in preventing chronic gout, patient adherence to
treatment remains low2. Recent
literature describes more severe and atypical manifestations of the disease.
The classic monoarticular involvement is becoming increasingly rare, with
atypical polyarticular presentations now more common3. Similarly, tophi, traditionally found
periarticularly or in avascular soft tissues such as the auricle of the toes4, have been reported in other organs5. Cutaneous dissemination of tophi has been
described as a rare dermatological manifestation of chronic gout6-9. We present the case of a 72-year-old
Malagasy patient with chronic gout, characterized by disseminated cutaneous
tophi, destructive polyarthritis and renal insufficiency.
Case Presentation
A 72-year-old man was
hospitalized in the Rheumatology department due to severe disabling pain in
both ankles and heels. His medical history was unremarkable, with no
hypertension, diabetes or alcohol use. He reported recurrent episodes of
debilitating joint pain over the past 42 years; each treated with injectable
diclofenac. He had undergone multiple surgical excisions of masses, diagnosed
as gouty tophi, on his hands. However, he had never received urate-lowering
therapy. The current episode began 10 days before admission with the sudden
onset of severe pain in both ankles and heels, accompanied by nocturnal pain
that resulted in an inability to walk. The appearance of spontaneous wounds on
his heels and the failure of pain relief with injectable diclofenac prompted
his hospitalization.
On Admission The
patient complained of persistent intense pain in both ankles and heels. His
blood pressure was 110/90 mmHg, heart rate was 84 bpm, temperature was 37.9°C
and BMI was 30 kg/m². Joint examination revealed fluctuating swelling in both
ankles, along with mild, painless flexion contractures affecting the hands,
elbows and knees. Cutaneous findings included surgical scars on the extensor
surfaces of the fingers; large, firm, painless subcutaneous masses on the
extensor surface of the metacarpophalangeal joint of the second left finger and
the left elbow, extending along the postero-external aspect of the left
forearm; diffusely infiltrated subcutaneous yellowish nodules, some ulcerated,
located on the legs, the left auricle and the extensor surface of the third
left finger (Figure 1). The remainder of the clinical examination was
unremarkable.
Figure 1: Left:
Surgical scar from tophus excision on the right hand. Center: Top: Large
subcutaneous tophus over the olecranon, Bottom: Large tophus over the
extensor surface of the distal interphalangeal and metacarpophalangeal joints. Right:
Disseminated subcutaneous tophi on the leg and tophus on the auricle of the
left ear
Biological and Imaging Findings Laboratory tests revealed an elevated CRP level of 100 mg/L, normocytic anaemia with haemoglobin at 87 g/L and renal insufficiency with a serum creatinine level of 185 µmol/L, corresponding to an estimated glomerular filtration rate (eGFR) of 35.77 mL/min/1.73m². Blood urea was 8.43 mmol/L and the electrolyte panel was within normal limits. Fasting blood glucose was 20.74 mmol/L, with a glycated haemoglobin level of 11.3%, indicating poorly controlled diabetes. Serum uric acid was elevated at 530 µmol/L. The lipid profile was abnormal, with a total cholesterol level of 5.24 mmol/L, HDL cholesterol at 0.92 mmol/L, LDL cholesterol at 2.95 mmol/L and triglycerides at 3.01 mmol/L. Cutaneous biopsies from different sites revealed monosodium urate crystals (Figures 2 and 3), confirming the diagnosis of diffuse cutaneous tophi. Conventional radiographs of the hands and feet showed signs of gouty arthropathy with multiple periarticular geodes. Renal and urinary tract ultrasound imaging demonstrated a dedifferentiated renal parenchymal pattern without evidence of lithiasis.
Figure 2: Left: Left leg-disseminated tophi sampled for
microscopic examination. Center: Monosodium urate crystals in a
needle-shaped formation observed under polarized light microscopy at 4×
magnification. Right: Monosodium urate crystals in a needle-shaped formation
observed under polarized light microscopy at 10× magnification
Figure 3: Left: Ulcerated tophus on the second left finger. Right:
Needle-shaped monosodium urate crystals observed in the biopsy sample from the
ulcerated tophus on the second left finger under polarized light microscopy at
4× magnification
Conclusion and
Management The patient presented with an acute gout flare superimposed on
chronic gout (disseminated cutaneous tophi, gouty arthropathy), along with
newly diagnosed uncontrolled diabetes, mixed dyslipidaemia and possible chronic
renal insufficiency. During hospitalization, he was treated with colchicine
(0.5 mg/day), prednisolone (30 mg/day for 3 days), atorvastatin (20 mg/day),
ramipril (10 mg/day) and insulin glargine (LANTUS®) (8 IU in the evening). His
condition improved, with resolution of the acute flare and stabilization of
fasting blood glucose levels. Upon discharge, the patient continued with the
same therapeutic regimen, supplemented by physiotherapy. He is scheduled for
follow-up to initiate febuxostat therapy. Additionally, he was referred to
endocrinology for diabetes management and nephrology for further evaluation of
his renal insufficiency.
Discussion
This case report
highlights the coexistence of both classic manifestations of gout and the rare
presentation of disseminated cutaneous tophi. The patient’s clinical profile is
characteristic of gout, with metabolic syndrome, a sedentary lifestyle, recurrent
arthritis, tophi, renal insufficiency and hyperuricemia10. Additionally, it illustrates the
challenge of ensuring patient adherence to treatment, as evidenced by the
absence of urate-lowering therapy despite the long-standing disease history.
Disseminated cutaneous involvement of tophi is an uncommon manifestation of
chronic gout7-9,11. Given the
diverse characteristics of the lesions, differential diagnoses include
subcutaneous calcinosis, rheumatoid nodules and eruptive xanthomas12,13. Cutaneous biopsies are essential to
confirm the diagnosis, as they reveal monosodium urate crystals7,9,11,14. The identification of monosodium
urate crystals remains the gold standard for diagnosing gout15. In our case, this step was made possible
by the recent availability of a polarized microscope in our department,
allowing for the detection of monosodium urate crystals in various lesion
sites. Risk factors for disseminated cutaneous tophi include obesity, chronic
venous insufficiency and long-term corticosteroid therapy6.
Conclusions
This case report
highlights the polymorphic presentation of gout. The identification of
monosodium urate crystals is crucial for confirming the diagnosis. Patient
adherence to treatment remains a significant challenge.
Author Contributions
1. Oliva Henintsoa
Rakotonirainy: contributed to the conceptualization, formal analysis,
and writing of the
original draft, as well as its revision and editing.
2. Marinah Hasintsoa
Solofoniaina: contributed to the writing of the original draft, as well as its
revision and editing.
3. Rajo Paidia
Radinasoa: supervised and validated the work.
4.Rakotonirina Lalao
Nomenjanahary: supervised and validated the work.
5. Fahafahantsoa
Rapelanoro Rabenja: provided resources and supervision.
Ethical Approval
The authors thank the
patient who provided written consent for this report. The authors have included
only the information necessary for scientific understanding.
Consent
Patient has provided
written consent for the publication of this report in accordance with the
journal consent policy.
Data Availability Statement
The data that support
the findings of this study are available from the corresponding author upon
reasonable request.
Conflict of Interest
The authors declare no
conflicts of interest.
Funding
No funding was received
for this study.
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