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Giant gouty tophi in the hands
Clinical Picture
Giant gouty tophi in the hands Bing Han, Liqiong Xue, Chengde Yang
A 59-year-old man was referred to Ruijin Hospital (Shanghai Jiao Tong University School of Medicine, Shanghai, China) with multiple nodules on his joints. The patient was previously diagnosed with gouty arthritis by visualisation of negative birefringent crystals in the joint aspirate. He took allopurinol and benzbromarone irregularly. In addition, our patient had hypertension and type 2 diabetes mellitus. Physical examination identified multiple gouty nodules (in the auricle, knee, ankle, hands, and toe joints); these were especially prominent in his hands (figure), where he had a severe loss of flexion and extension. Biochemical examination showed he had raised creatine (137 μmol/L; normal range 62–115 μmol/L) and uric acid concentrations (725 μmol/L; normal range 208–428 μmol/L). He was diagnosed with advanced erosive tophaceous gout and was given febuxostat treatment to reduce uric acid concentrations. After a month of treatment, uric acid concentrations fell to 578 μmol/L. The patient was reluctant to have his uric acid concentrations checked again or to have surgical treatment. As a result, we do not know the patient’s current uric acid concentration. A
Gout is a common metabolic disease caused by deposition of monosodium urate crystals in peripheral joints. Tophi are formed by nodular accumulation of monosodium urate crystals in soft tissue that usually appear in the metatarsophalangeal joint or knee. However, tophi in the hands are not common. Tophi usually present in patients who have had gouty arthritis for at least 10 years. The primary therapy is treatment with antihyperuricemic drugs. The ideal uric acid concentration for resorption of gouty tophi is less than 357 mmol/L. Surgical removal of tophi is also reported to reduce pain, maximise function, and improve cosmesis. Contributors BH wrote the manuscript. LX collected data and followed up with the patient. CY did the physical examination of the patient and revised the manuscript. Declaration of interests We declare no competing interests. Acknowledgments This work was supported by grants from the National Natural Science Foundation of China (number 81200416) and Shanghai Municipal Health Bureau (number 20124262).
Lancet Diabetes Endocrinol 2016 Published Online February 19, 2016 http://dx.doi.org/10.1016/ S2213-8587(15)00420-9 Department of Endocrinology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (B Han MD); Department of Endocrinology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China (L Xue MD); and Department of Rheumatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (C Yang MD) Correspondence to: Dr Chengde Yang, Department of Rheumatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China [email protected]
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Figure: Giant gouty tophi in hands of a 59-year-old man
www.thelancet.com/diabetes-endocrinology Published online February 19, 2016 http://dx.doi.org/10.1016/S2213-8587(15)00420-9
1
Giant gouty tophi in the hands Bing Han, Liqiong Xue, Chengde Yang
A 59-year-old man was referred to Ruijin Hospital (Shanghai Jiao Tong University School of Medicine, Shanghai, China) with multiple nodules on his joints. The patient was previously diagnosed with gouty arthritis by visualisation of negative birefringent crystals in the joint aspirate. He took allopurinol and benzbromarone irregularly. In addition, our patient had hypertension and type 2 diabetes mellitus. Physical examination identified multiple gouty nodules (in the auricle, knee, ankle, hands, and toe joints); these were especially prominent in his hands (figure), where he had a severe loss of flexion and extension. Biochemical examination showed he had raised creatine (137 μmol/L; normal range 62–115 μmol/L) and uric acid concentrations (725 μmol/L; normal range 208–428 μmol/L). He was diagnosed with advanced erosive tophaceous gout and was given febuxostat treatment to reduce uric acid concentrations. After a month of treatment, uric acid concentrations fell to 578 μmol/L. The patient was reluctant to have his uric acid concentrations checked again or to have surgical treatment. As a result, we do not know the patient’s current uric acid concentration. A
Gout is a common metabolic disease caused by deposition of monosodium urate crystals in peripheral joints. Tophi are formed by nodular accumulation of monosodium urate crystals in soft tissue that usually appear in the metatarsophalangeal joint or knee. However, tophi in the hands are not common. Tophi usually present in patients who have had gouty arthritis for at least 10 years. The primary therapy is treatment with antihyperuricemic drugs. The ideal uric acid concentration for resorption of gouty tophi is less than 357 mmol/L. Surgical removal of tophi is also reported to reduce pain, maximise function, and improve cosmesis. Contributors BH wrote the manuscript. LX collected data and followed up with the patient. CY did the physical examination of the patient and revised the manuscript. Declaration of interests We declare no competing interests. Acknowledgments This work was supported by grants from the National Natural Science Foundation of China (number 81200416) and Shanghai Municipal Health Bureau (number 20124262).
Lancet Diabetes Endocrinol 2016 Published Online February 19, 2016 http://dx.doi.org/10.1016/ S2213-8587(15)00420-9 Department of Endocrinology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (B Han MD); Department of Endocrinology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China (L Xue MD); and Department of Rheumatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (C Yang MD) Correspondence to: Dr Chengde Yang, Department of Rheumatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China [email protected]
B
Figure: Giant gouty tophi in hands of a 59-year-old man
www.thelancet.com/diabetes-endocrinology Published online February 19, 2016 http://dx.doi.org/10.1016/S2213-8587(15)00420-9
1