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Background To report the occurrence of tophaceous gout in the cervical spine and to review the literature on spinal gout. Case presentation This report details the occurrence of a large and clinically significant finding of tophaceous gout in the atlantoaxial joint of the cervical spine in an 82-year-old Caucasian man with a 40-year history of crystal-proven gout and a 3-month history of new-onset progressive myelopathy. The patient's American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria score was 15.0. Conclusion Spinal gout is more common than previously thought, and it should be considered in patients who present with symptoms of myelopathy. Diagnosis can be made without a tissue sample of the affected joint(s) with tools like the ACR/EULAR criteria and the use of the “diagnostic clinical rule” for determining the likelihood of gout. Early conservative management with neck immobilization and medical management can avoid the need for surgical intervention.

Baseline and follow-up DECTs were performed under a standard ULT protocol. Monthly dissolution rates were calculated by simple and compound methods. Correlations with average SU were compared and analyzed. Best-fit regression model was identified. MSU dissolution times were plotted against SU at different endpoints.In 29 tophaceous gout patients, MSU volume reduced from baseline 10.94 ± 10.59 cmMSU dissolution is better described as a logarithmic function of SU, which explains, predicts, and facilitates understanding of the dissolution process.

Gout is common crystal arthritis that is often managed sub-optimally.To determine what proportion of patients treated for gout by the tertiary level rheumatology service at the Royal Brisbane Hospital between 2014 and 2018 reached target serum urate (SU) levels. Secondary aims included exploring the demographic characteristics of those who did and did not reach target.The records of patients who were treated at least once either as in inpatient or outpatient by the rheumatology service at the Royal Brisbane Hospital between 1 January 2014 and 31 December 2018 were reviewed. Clinical status, treatment characteristics and outcome were recorded and analysed.There were 129 patients who met the inclusion criteria for the study, the majority of patients were male and 39% had tophaceous gout. Fifty-four (42%) had been intentionally discharged from clinic, 50 (85%) of those patients had reached their SU target, the remaining eight (15%) were discharged with a plan for other services to continue their therapy to reach SU target. Forty patients (31%) had ongoing follow up, with 16 (40%) of these at target and 24 (60%) not at target. Thirty-five (27%) were not attending, five (4%) had died and 30 (23%) had failed to attend follow-up appointments, none of these patients was at target at their last known SU level.Despite effective therapy the number of patients treated for gout at a large public metropolitan teaching hospital reaching SU target was low. Almost one-quarter of patients in the study discontinued contact with the clinic. The reasons for this are not clear and are likely multifactorial.

Tophaceous gout of the middle ear is a rare occurrence that presents as a granular white-colored mass. It is frequently misdiagnosed as cholesteatoma or tympanosclerosis in patients who otherwise may not manifest any clinical or biochemical signs of gout. While uncommon, it can lead to clinically significant disease such as conductive hearing loss. The present report describes 2 cases of middle ear gouty tophi initially mistaken for another entity. Both patients underwent surgery, and the diagnosis of gout was revealed after final histopathological analysis. A review of the literature is also presented.

Medical treatment with urate-lowering therapy (ULT) is efficacious. A recent publication suggested that surgery in gout is more prevalent than previously reported. This revelation led us to review what is known about surgical treatment of gout. The Google Scholar database (January 1, 2014–January 1, 2020) found 104 publications with a total of 169 gout patients, with an average disease duration of 6.7 years. Most (68%) were not on ULT. The mean pre-operative serum urate levels were 9.19 mg/dL. One hundred thirteen patients underwent tophi excision, while in 33 patients, tophi were found during surgery. The majority of the surgeries were performed in Asia and Europe. Most patients were not taking ULT at the time of surgery, leading to hyperuricemia. This can result in tophi reformation post-surgery. The role of surgery should be a last-line treatment and until recently has only been demonstrated through case reports.

Gout is the most common inflammatory arthritis and is increasing in prevalence and incidence in many countries worldwide. Dual Energy Computed Tomography (DECT) has a high diagnostic accuracy in established gout, but its diagnostic sensitivity is low in subjects with recent-onset gout. A meta-analysis of 17 studies showed a pooled sensitivity and specificity of 0.85 and 0.88, respectively. DECT is a useful diagnostic tool for patients with contraindications for joint aspiration or for those who refuse joint aspiration. This article aims to give an up to date review and summary of existing literature on the role and accuracy of DECT in the imaging of gout. (www.actabiomedica.it)

Disseminated cutaneous gout is a rare atypical cutaneous manifestation of gout in which widespread dermal and subcutaneous tophi develop at extra-articular body sites. Given the lack of joint involvement that is typically a feature in tophaceous gout, the diagnosis may not be initially suspected. We present the case of a 50-year-old Hispanic man with poorly controlled gout who was evaluated for several years of firm papulonodules over the trunk and upper and lower extremities, sparing the joints; histopathology confirmed, the diagnosis of disseminated cutaneous gout. Per our literature review, disseminated cutaneous gout presents with polymorphous papules and nodules that can mimic other, more common cutaneous diseases. There is a preponderance of cases in males, Asians, and patients with longstanding gout. The lower extremities are involved in nearly all reports. Uric acid-lowering therapy with allopurinol has been reported to decrease the size and number of lesions in a minority of treated patients.

To provide information from a review of the literature about chronic ulcers associated with tophaceous gout.This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After participating in this educational activity, the participant should be better able to:1. Identify the pathophysiology of tophaceous gout, its presentation, phases, and common comorbidities.2. Evaluate the findings in this review regarding effectiveness of interventions for chronic tophaceous ulcers.OBJECTIVE: Treating chronic ulcers associated with tophaceous gout is an uncommon but important clinical challenge. However, treatments vary greatly from topical therapies, to debridements, to free flap wound coverage. To the authors' knowledge, this is the first study to assemble and compare these different approaches in order to guide effective treatment.An electronic search of MEDLINE (PubMed) was conducted. Search terms included (gout and ulcer) not "peptic ulcer," and (gout, chronic wound) or (gout, nonhealing wound).Studies that discussed the presentation, characterization, or treatment of gout-associated wounds were included. The literature search yielded 9 case reports and case series; there were no randomized controlled studies or reviews.Patient and wound characteristics, treatment approaches, and outcomes were noted.The 82% of 22 patients were male, aged 36 to 95 years. Three patients had not been previously diagnosed with gout, whereas others had received a diagnosis 2 to 35 years prior to presentation with an ulcer. Many patients had comorbidities including diabetes and peripheral vascular disease. Most of the 43 total ulcers occurred on the feet. Treatments included topical 3% citric acid in petroleum jelly, allogeneic culture dermal substitute, silver-containing dressing and heterologous lyophilized collagen, debridements, and free flap coverage.Chronic tophaceous wounds are a worldwide problem. Although physicians report some successes with different treatments, controlled studies are needed to determine the most effective approach and to identify risk factors and preventive strategies.

The objective was to determine the reduction of tophi in patients undergoing drug therapy in correlation with urate serum levels through ultrasound examination. A total of 31 male patients, between the ages of 33 to 77 years, with tophaceous gout were evaluated between 2005 and 2009, 11 of which were selected. Ultrasound examinations of visible tophi and evaluations of serum uric acids levels were performed annually on each patient. There was a statistically significant difference between measurements 1, 2, 3 and measurement 4 and between measurements 4 and 5. A strong significant positive association was seen between variation of tophus size and the reduction of serum uric acid levels.

A 46-year-old man with over a 10-year history of gout complained of progressive bilateral buttock pain with numbness of legs for 4 months. Serum uric acid level was elevated. Lumbar radiographs showed decreased density of the bilateral L4-L5 facet joints. CT showed lytic lesions of the facet joints with hyperdense periarticular lesions. Enhanced MRI showed marked enhancement of these lesions. FDG PET/CT showed avid FDG uptake of the bony and periarticular lesions with SUVmax of 16.8. A decompressive posterior lumbar laminectomy with periarticular lesion resection was performed. Histopathologic findings of the periarticular lesions were consistent with tophaceous gout.

Gout refers to an inflammatory condition caused by deposition of urate crystals in joints leading to painful arthritis.[1][1] Tophaceous gout occurs due to collection of urate crystals in subcutaneous and soft tissue. Unlike primary gout where the aetiology lies in malfunction of uric acid

Background:Gout is a purine metabolism disease. Tophaceous gout may cause joint destruction and other systemic problems and sometimes may be complicated by infection. Infection and sinus with discharge associated with tophaceous gout are serious complications, and treatment is difficult. We present a patient with tophaceous gout complicated by infection and discharging sinus treated by bilateral amputation at the level of the first metatarsus.Methods:A 43-year-old man previously diagnosed as having gout, and noncompliant with treatment, presented with tophaceous gout associated with discharging sinus and infection on his left first metatarsophalangeal joint. Because of the discharging sinus associated with the tophaceous deposits, the soft-tissue and bony defects, and the noncompliance of the patient, amputation of the first ray was undertaken, and a local plantar fasciocutaneous flap was used to close the defect. After 8 months, the patient was admitted to the emergency department with similar symptoms in his right foot, and the same surgical procedure was performed.Results:One year after the second surgery, the patient had no symptoms, there was no local inflammatory reaction over the surgical areas, and laboratory test results were normal.Conclusions:Gout disease with small tophi often can be managed conservatively. However, in patients with extensive lesions, risk of superinfection justifies surgical treatment. Results of complicated cases are not without morbidity; therefore, early surgical treatment may prevent extremity loss and further complications. In severe cases, especially with compliance issues, amputation provides acceptable results.

Gout is a common cause of inflammatory arthritis. The classical treatment options in an acute gout attack are non-steroidal anti-inflammatory drugs, colchicine, and corticosteroids. Interleukin-1 inhibition has been shown to be an effective alternative when non-biologic therapies are ineffective or contraindicated. Herein, we report the case of a 69-year-old female who presented with polyarticular tophaceous gout treated successfully with anakinra.

Objective.Age of onset of gout has recently decreased; however, patients with early-onset gout remain uncommon, and relevant information is scant. We hypothesized that these patients might exhibit differences in serum urates and other comorbidities compared with adult-onset patients.Methods.Early-onset gout patients (i.e., juveniles) with (n = 40) and without tophi (n = 47) were enrolled for study. Their clinical characteristics were compared with those of 353 patients with middle-age-onset tophaceous gout and 64 age-matched healthy participants.Results.Early-onset gout patients with tophi exhibited significantly higher body mass indices and serum urate levels and lower estimated glomerular filtration rates (eGFR) than did those without tophi. Early-onset gout patients with or without tophi demonstrated significantly abnormal lipid profiles and impaired liver or renal function compared with healthy patients. Serum urate levels and gout duration were identified as the principal determinants of tophi development. The presence of tophi might be crucial in decreasing eGFR, which is inversely related to tophi duration or gout duration. Unexpectedly, the most common site of initial gout attacks in early-onset tophaceous gout patients was the ankle, not the toe, which was the most common site in middle-age-onset tophaceous gout patients. The most common site of first tophi occurrence in early-onset patients was a finger, not a toe, which was the most common site in middle-age-onset patients.Conclusion.Early-onset tophaceous gout patients are more likely to exhibit comorbidities and renal dysfunction than middle-age-onset patients and exhibit distinct first sites of gout attack and tophi occurrence patterns.

Objective.To investigate the joint effects of alcohol consumption and ABCG2 gene variants on tophaceous gout occurrence.Methods.The V12M (rs2231137), Q126X (rs72552713), and Q141K (rs2231142) of the ABCG2 gene were genotyped among controls, nontophaceous, and tophaceous gout cases in Taiwanese Han (n = 446, 77, 177) and Taiwan Aborigines (n = 1105, 203, 330).Results.The missense variations V12M (C) and Q141K (T) significantly associated with tophaceous gout (p trend = 4.08 × 10−2, 9.00 × 10−12 in Han; 1.81 × 10−3, 9.34 × 10−10 in Aborigines). The nonsense variation Q126X (T) exerted a significant effect only in Han (p = 1.10 × 10−2), but not in Aborigines. In the prediction of tophaceous gout, the Q141K (T) OR were 1.51 in Han, 1.50 in Aborigines, and 1.55 (p = 7.84 × 10−5) in pooled analysis when compared to nontophaceous gout. We found the joint effects of alcohol consumption and Q141K (T/T) highly associated with tophaceous gout (adjusted OR ≥ 5.11; p ≤ 7.78 × 10−4); specifically the ever drinkers carrying the Q141K (T/T; adjusted OR 25.05, p = 9.21 × 10−4 in Han; adjusted OR 14.87, p = 1.08 × 10−8 in Aborigines).Conclusion.Our findings showed alcohol consumption and ABCG2 Q141K, independently and jointly, associated with the risk of chronic tophaceous gout.

CASE A 17-year-old man experienced night pain in his right hallux. Radiographs revealed a lytic lesion in the proximal phalanx of the right hallux. Magnetic resonance imaging showed a low-signal intensity mass on T1-weighted sequences and isointense-high-signal intensity on T2-weighted sequences. We suspected a benign bone tumor such as osteoid osteoma or a bone cyst and consequently performed biopsy and surgical treatment. The lesion was filled with a whitish chalk-like substance, and pathologic examination revealed tophaceous gout. CONCLUSIONS It can be difficult to distinguish intraosseous tophaceous gout from other diseases, including bone tumors, using imaging; hence, pathological examination may be necessary for the diagnosis.

Gout is the most common form of microcrystalline arthropathy which usually does not pose a diagnostic challenge when patients have typical presentation, appropriate biochemical picture and classical radiographic appearance. However, formation of gouty tophi in unusual locations and with atypical presentations may mislead clinicians and radiologists, thereby justifying gout nickname as the “great mimicker”. When interpreting images of tendon related masses, radiologists should be aware of gouty tophi as a possible differential given its variable and nonspecific imaging appearance. In this article, we present a case of a patient with a painless tophaceous gout nodule, adjacent to the Achilles tendon.

Gout is caused by the overproduction of uric acid and the inefficient metabolism of dietary purines in humans. Current treatments of gout, which include anti-inflammatory drugs, cyclooxygenase-2 inhibitors, and systemic glucocorticoids, have harmful side-effects. Our research laboratory has recently introduced an innovative approach for the decrystallization of biological and chemical crystals using the Metal-Assisted and Microwave-Accelerated Evaporative Decrystallization (MAMAD) technique. In the MAMAD technique, microwave energy is used to heat and activate gold nanoparticles that behave as “nano-bullets” to rapidly disrupt the crystal structure of biological crystals placed on planar surfaces. In this study, crystals of various sizes and compositions were studied as models for tophaceous gout at different stages (i.e., uric acid as small crystals (~10–100 μm) and l-alanine as medium (~300 μm) and large crystals (~4400 μm). Our results showed that the use of the MAMAD technique resulted in the reduction of the size and number of uric acid and l-alanine crystals up to >40% when exposed to intermittent microwave heating (up to 20 W power at 8 GHz) in the presence of 20 nm gold nanoparticles up to 120 s. This study demonstrates that the MAMAD technique can be potentially used as an alternative therapeutic method for the treatment of gout by effective decrystallization of large crystals, similar in size to those that often occur in gout.

AIM To investigate whether plain radiography is useful for assessing the changes in gouty tophi size following hypouricemic therapy. METHODS Gout was diagnosed according to the American College of Rheumatology criteria. Before and after hypouricemic treatment, serum uric acid level was measured, and plain radiography was performed to measure gouty tophi size. The tophi were graded by measuring the maximum vertical and horizontal diameters, and they were scored by adding up the scores of the grades. The vertical diameter was measured on both sides of the proximal phalanges (PPs). The horizontal diameter was measured on the lateral side of the PPs. The maximum vertical diameter measurement was graded 0-4. The maximum horizontal diameter measurement was graded 0-3. RESULTS Seven hundred first metatarsal phalangeal joints (MTPJ) of 350 patients with gout were assessed for gouty tophi. Tophi were observed using plain radiography in 174 MTPJs (24.9%) of 109 patients (31.1%). Follow-up plain radiography was performed in 60 of these patients. Before the treatment, the average serum uric acid level of these patients was 8.3 ± 1.9 mg/dL, and the average tophi score was 3.7 ± 2.5. After hypouricemic treatment, the uric acid level decreased to 5.9 ± 1.6 mg/dL (P < 0.05), and the average tophi score decreased to 1.5 ± 1.8 (P < 0.05). CONCLUSIONS This new method for measuring gouty tophi using plain radiography may be useful for evaluating changes in gouty tophi size following hypouricemic treatment.

Epidemiologic data from recent decades show a significant increase in the prevalence and incidence of gout worldwide, in addition to changes in its clinical expression. Our objective was to compare the frequency of the severity of gout and disability in two patient groups at our clinic during different periods. We included and compared data of two groups: group A (1995–2000), patients from previous report, and group B (2010–2014), the baseline data of current patients participating in a cohort (GRESGO). This evaluation included data of socioeconomic and educational levels, demographics, associated diseases, previous treatment, clinical and biochemical data, and disability evaluated using the Health Assessment Questionnaire (HAQ). We included data of 564 gout patients. Participants were 35.7 ± 12.7 years old at onset and had 12.0 ± 9.2-years disease duration at their first evaluation in our department. Group B patients were younger, had higher educational and socioeconomic levels, and had more severe disease. However, this group had less frequency of some associated diseases and significantly higher HAQ scores. With increased HAQ score, a higher number of acute flares and tender, limited-to-motion, and swollen joints were seen. The spectrum of gout has changed over the past decade. A higher percentage of our patients had a severe form of disease, were younger, had earlier disease onset, and had more disability reflected in higher HAQ scores. In our current patient group, the variable most associated with disability was limited-to-motion joints; however, the number of acute flares and tender and swollen joints was also higher in patients with greater disability.

The cervical spine is a rare site where tophaceous gout has been identified. There are currently 15 described cases in the literature of gouty involvement of the cervical spine with only three cases involving only the atlanto-axial region. We add the fourth of such cases and only the second to be managed operatively.

Gout is often considered a disease of an excessive lifestyle, a ‘malady of kings’. Today, more than 1% of the European and US populations are afflicted with gout, although ulceration over gout tophi remains uncommon. We describe four cases of ulceration associated with gout tophi to highlight the clinical presentation, complications and a management strategy.

Gout is a common rheumatologic condition with characteristic clinical presentations during the acute arthritis and chronic tophaceous stages. Because of this, there is a tendency to overlook rare but important conditions which are independent of, but can co-exist with gout. This case of severe hip and knee pain in a patient with tophaceous gout takes the reader on a problem-solving exercise which simulates the analytical processes and decisions made in the clinic.

We describe a case of tophaceous gout with a combination of carpal tunnel syndrome and finger movement dysfunction. Carpal tunnel syndrome secondary to gout is uncommon. The concomitant presence of finger movement dysfunction is rare and suggests the involvement of the flexor tendons inside the carpal tunnel. Surgery is recommended to decompress the median nerve, to confirm the diagnosis, and for immediate improvement of flexor tendon excursion. Our patient's finger movement improved dramatically soon after surgery.

Michelangelo, the great Renaissance artist, is often included on lists of celebrated gout patients. His letters describe a single acute attack of foot pain at the age of 80, but a case for early onset has been presented, based on a fresco by a contemporary artist, Raphael. A figure resembling Michelangelo at the age of 36 appears to have nodules resembling tophi over his knees.In this report, we review Michelangelo's medical history, discuss the proposal that he had tophaceous gout, and address the significance of "knobby" knees in his works and those of other artists.

Although unusual, tophi in the absence of prior episodes of gouty arthritis can be the initial manifestation of gout1. Atypical triggering at the wrist and carpal tunnel syndrome because of intratendinous infiltration of tophaceous gout have been described only in older patients2,3. A 20-year-old man was referred for the inability to extend the middle and ring fingers of the right hand, which was getting progressively …

Patients in the United States without private medical insurance and who do not qualify for patient assistance programs sometimes have no access to needed medications. The most effective drugs for severe tophaceous gout may be beyond the reach of these patients. A 49-year-old undocumented male Mexican immigrant presented to the emergency room with foot pain, left greater than right. He had a history of chronic diffuse tophaceous gout (Figure …

The tophus is the cardinal feature of advanced gout. This review summarises recent research into the biology, impact and treatment of tophaceous gout. Microscopically, tophi are chronic foreign body granuloma-like structures containing collections of monosodium urate (MSU) crystals surrounded by inflammatory cells and connective tissue. Extracellular trap formation mediated by neutrophil interactions with MSU crystals may be a central checkpoint in tophus formation. Gouty tophi impact on many aspects of health-related quality of life. Tophi are also implicated in the development of structural joint damage and increased mortality risk in people with gout. Effective treatment of tophaceous gout requires long-term urate-lowering therapy, ideally to achieve a serum urate concentration of

A 56-year-old white woman was referred to our institution with a 16-month history of severe, gouty, recurrent, acute polyarthritis involving the finger joints. She also had numerous small subcutaneous tophi in her hands. The patient was intolerant to allopurinol and had mild renal insufficiency attributed to uric-acid nephrolithiasis and interstitial nephropathy.Physical examination, laboratory testing, X-rays of the hands, feet and pelvis, CT of the pelvis, microscopic analysis of an aspirate from a finger tophus.Tophaceous gout associated with urate nephropathy in a patient intolerant to allopurinol.Acute polyarthritis was successfully managed by intravenous bolus methylprednisolone combined with codeine, diclofenac and low-dose colchicine. Rasburicase infusions combined with fenofibrate and sodium bicarbonate achieved to maintain serum acid uric below 360 micromol/l.

The ulceration associated with gout tophi is very difficult to treat because of impaired and halted local inflammatory response resulting from the gout treatment regimen. We report chronic nonhealing tophaceous gout with bursitis in an 80-year-old male, not responding to conventional treatment modality for months together. This nonhealing ulcer was treated successfully with local application of 3% citric acid ointment for 22 days.

Spontaneous rupture of the extensor pollicis longus (EPL) tendon has been reported in the literature. Various mechanisms have been proposed to account for this problem, but gouty infiltration is a rare mechanism. Here we report a patient with a long-standing history of gout who presented with sudden loss of interphalangeal extension of the left thumb. Spontaneous rupture of the EPL tendon caused by gout was discovered. The successful treatment done involved surgical exploration and extensor indicis proprius tendon transfer. Postoperative thumb spica immobilization for 6 weeks was applied. Pathology disclosed urate crystals deposited within the ruptured EPL tendon. The functional recovery is satisfactory at the 1-year follow-up. Spontaneous rupture of the EPL tendon caused by gout is rare. Successful treatment was done with surgical management. Life-long medical follow-up to prevent a repeated acute attack can lower the risk of a large amount of tophaceous gout infiltration in tendons and may possibly prevent acute spontaneous tendon rupture.