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Chronic tophaceous gout

Article  in  QJM: monthly journal of the Association of Physicians · January 2017

DOI: 10.1093/qjmed/hcx019

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Mazandaran University of Medical Sciences
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CASE REPORT
Chronic tophaceous gout
M. Jabalameli, A. Bagherifard, H. Hadi, V. Behshad and S. Ghaffari
From the Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of
Medical Sciences, Tehran, I.R. Iran
Address correspondence to S. Ghaffari, Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences,
Tehran, I.R. Iran. email:orthosalman@yahoo.com
Learning point for clinicians
• Gout is not a benign disease. Patient noncompliance or
clinician mismanagement can cause severe tophaceous
gout with joints destruction, stiffness and compromised
quality of life. Patient may need surgical decompression
of nerves, tophus resection or joint replacement.
Case report
We report 61-year old man with 30 years of poorly controlled
gout, referred to our clinic because of difficulty in walking and
activities of daily life. The first presentation of disease was
acute painful swelling posterior to left medial malleolar region.
Because of positive family history serum uric acid level was
checked and high level identified. His father, five of seven
uncles and his brother have gout. No history of smoking, he
drinks alcohol occasionally but does not have high purine diet.
He was no cooperative on drug consumption, taking allopurinol
occasionally, sometimes with colchicine and NSAIDs at 2002
after 1 year of right knee pain, open joint debridement was per-
formed and gout confirmed by pathologist. The knee was pain-
less until 8 years which arthroscopic debridement, inercondylar
notchplasty and loose bodies removal was performed at 2006
left knee was debrided and loose bodies removed arthroscopi-
cally. At the same year left carpal tunnel release was performed
because of median nerve compression. At 2013 platlet-riched
plasma was injected into the left knee. At 2014 left first metatar-
sophalangeal joint area tophus was excised. Right knee range of
motion (ROM) is between 30 and 90 degrees of flexion (0-30-90)
and left knee ROM is 45–70 degrees (0-45-70). Now, because of
both knees severe flexion contracture and stiffness, he cannot
walk without support.
Both wrists, both elbows, both feet and right shoulder affected
by tophi, which painless limited ROM was the chief complaint.
Submitted: 29 November 2016; Revised (in revised form): 1 January 2017
C The Author 2017. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved.
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QJM: An International Journal of Medicine, 2017, 239–240
doi: 10.1093/qjmed/hcx019
Advance Access Publication Date: 17 January 2017
Case report
In both knees tricompartmental degeneration with osteo-
phyte formation and ossified mass in posterior joint space can
be seen. In right knee significant swelling of inferior superficial
prepatellar bursa and in left knee ossification in suprapatellar
pouch, lytic lesion in proximal pole of patella is seen.
Laboratory tests show serum uric acid level 9.6 mg/dl (normal
3.8–6.6 mg/dl), HbA1C 7.4, FBS 108, C-reactive protein 0.05 mg/dl
(normal < 0.06 mg/dl) and serum creatinine 0.82 mg/dl (normal
0.63–1.03 mg/dl). In abdominal ultrasonography there was one 5-
and one 7-mm calculus in left kidney and gallbladder
respectively.
Because of knee joint osteoarthritis, flexion contracture,
stiffness and difficulty in walking and daily activities he is can-
didate for total knee replacement (Figure 1).
Discussion
Recent studies have shown changes in gout epidemiology. Men
especially in older age groups are more affected by gout.
Mismanaged poorly controlled gout after a long time may result
in chronic tophaceous gout.1,2 Lo  pez et al.2 have shown that in
the last decade younger patients with earlier onset and more
disabling form of gout are identified. Limited joints ROM were
the main cause of disability in their patients. knee instability
may result from anterior and posterior cruciate ligaments dys-
function secondary to knee intraarticular tophi.3
The mainstay of Gout and established tophi management is
appropriate drugs to control serum uric acid level. Even in cases of
painless asymptomatic incidentally diagnosed tophi, the patient
must be managed with appropriate drugs to avoid complications
such as cardiac or renal failure and joint destruction and limited
ROM.4 Open or arthroscopic debridement is one option to manage
knee joint dysfunction caused by intra-articular tophi.5 Despite of
usual concept that gout is a benign disease not result in terminal
joint destruction, long-standing poorly controlled gout can cause
239
 240 | QJM: An International Journal of Medicine, 2017, Vol. 110, No. 4

Figure 1. Knee flexion contracture. A standing position, B supine position.

multiple joints dysfunction. In advanced, terminal knee joint de- 3. Cetin P, Tuna B, Secil M, Akar S. Tophaceous gout causing
struction patient may benefit from joint replacement.6 internal derangement of knee joint. J Clin Rheumatol 2014;
20:235.
Conflict of interest: None declared.
4. Asahara M, Hoashi T, Shirakawa N, Matano Y, Funasaka Y,
Takayama Y, et al. Chronic tophaceous gout with multiple
large tophi. J Dermatol 2016. Sep 7. doi: 10.1111/1346-
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