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Carpal tunnel syndrome is the most common peripheral compression neuropathy and can be caused by many diseases and conditions, including the formation of gouty tophi in various structures of the tunnel. This publication provides a review of literature and a case report on Carpal tunnel syndrome in a 58-year-old male patient with tophaceous gout. The case is characterized by the extremely rare combination of median nerve compression and tendons dysfunction due to the tophi deposits in the flexor tendons of the hand.

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.

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.

Ulcers resulting from tophaceous gout are uncommon and very difficult to heal. Here we report a case with chronic refractory tophaceous gout, not responding to conventional treatment modality for several months in a 39-year-old man with a 12-year history of gout with recurrent acute arthritis attacks. Two times after treatment with autologous platelet-rich gel (APG), the ulcer healed finally for 2 months. This is the first study to confirm that APG can improve tophus ulcer healing. Based on conventional medical therapy and standard debridement, APG might be a novel and effective method to stimulate tophus ulcer healing.

A 48-year-old man visited the emergency room with right hip pain that started abruptly while walking out of the bathroom. Computed tomography showed an intraosseous mass in the femoral neck. The patient had a 15-year history of gout and had numerous bilateral tophi in his hands, feet, knees, and elbows. After operation, we diagnosed a pathological fracture due to intraosseous tophi. Patients with hip pain who have many subcutaneous tophi and long-standing gout should be diagnosed carefully. Peri-hip joint pain caused by gout is uncommon, however, if a patient complains of pain, a simple X-ray may be required. If intraosseous tophi are present, appropriate treatment (e.g., strict hyperuricemia control with or without prophylactic internal fixation), may be required before fracture occurs.

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.

Patellar tumors are rare entities, representing only 0.12% of all bone tumors in the United States...

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.

BACKGROUND: Gout is a condition characterized by abnormally elevated levels of uric crystals (gouty tophi). It is often to detect in the foot and ankle. Occasionally such tophus is found at rare sites and makes a challenge to the clinician where diagnosis and treatment are concerned. CASE REPORT: We present a patient who presented to our oncology department with pain on her right hip. It was diagnosed as a benign tumor by the clinical and radiological assessment but intraoperatively turned out to be gouty tophi. Excision surgery has performed, in the 1-year follow-up; there is no relapse of pain. CONCLUSIONS: Tophaceous gout in the hip joint is a rare case, which clinical and radiology assessments can detect erroneous diagnose. Tophaceous gout in the hip joint mimicked the bone tumor characteristics. It requires a better application and diagnosed for the mimicked tophaceous gout.

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.

Carpal tunnel syndrome (CTS) is well recognized as the most common type of peripheral neuropathy. A rare cause of CTS is tophaceous gout. Tophi deposits can accumulate in various structures including the flexor tendons, tendon sheaths, the carpal tunnel floor, transverse carpal ligament, and even the median nerve, causing various symptoms such as pain, numbness, and weakness. Tophi forming in the carpal canal can compress the median nerve, leading to CTS. Here, we describe a 25-year-old male with a family history of tophaceous gout who presented with typical CTS symptoms. Although he had chronic numbness in his right hand, he failed to present with any obvious palpable masses on his forearm or hand. However, his family history, laboratory, clinical, and magnetic resonance imaging findings were consistent with tophi deposits. CTS symptoms were eased through surgical removal of tophi and decompression of the median nerve. No recurrences of gout and CTS symptoms were reported at a one-year follow-up. This case shows that CTS symptoms could be the initial manifestation of tophaceous gout. In patients with a family history of gout and with CTS symptoms, imaging examinations are critical for early diagnosis and selecting appropriate treatment. Surgical removal of "covert" tophi and decompression of the median nerve is an effective option for eliminating symptoms.

We present a very rare case of tophaceous gout of the middle ear causing conductive hearing loss, with special emphasis on Computed Tomography presentation. Keywords: Gout, Middle ear, Hearing loss, Conductive hearing loss, Computed tomography

Objectives Tophaceous gout seldom affects the axial skeleton. Symptoms vary according to the differential localization of urate deposits and the diagnosis is often delayed. Here, we report an unusual case of lumbar spinal stenosis caused by extradural tophaceous deposits. Methods We retrospectively reviewed a case of a patient with tophaceous gout of the lumbar spine and reviewed the relevant literature. Results A 62-year-old man with a 2-year history of lower back pain and a 3-month history of lower limb radiation pain and intermittent claudication was admitted. After laboratory and imaging investigations he underwent surgical decompression and stabilization. Histological analysis of the extracted specimen confirmed that it was gouty tophus. The patient's symptoms improved progressively after the operation. He recovered very well with no complications. Conclusion The mechanism associated with axial gout is not yet clear. Obesity, inactivity, and previous degenerative disc disease may be the risk factors for spinal tophus. The clinical symptoms are diverse according to the differential localization of urate deposits. It is not easy to diagnose this disease radiographically by routine radiological examination. Analysis of a biopsy specimen is definitely the only way to confirm diagnosis. Surgical treatment should be considered in patients with spinal gout who are experiencing neurological deterioration.

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 management of gouty tophi has generally shifted from surgical excision to conservative therapy due to surgery’s traditional association with high wound complication rate. Yet there are still patients who are indicated for surgical excision of gouty tophi, including for functional or cosmetic reasons. We describe our surgical technique and clinical outcomes in patients who underwent gouty tophi excision. This technique includes near complete excision of non-infected gouty tophi with preservation of important soft tissue structures. We have performed 44 elective tophi excision surgery in ten patients with an average follow-up of 29 months. The overall patients’ satisfaction rate was 90%. Only one post-operative infection was noted. No recurrence was observed. Our results suggested that this technique is a safe and effective option for a selected group of patients suffering from tophaceous gout.

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.

Background With increasing prevalence of gout world-wide, ulceration associated with tophaceous gout is becoming increasingly common in recent years. Investigation of the clinical characteristics and risk factors will allow us to better understand the fact of ulceration over tophi and improve the management for such challenge problem. Objectives To describe clinical characteristics of ulceration over tophi in patients with gout and determine risk factors associated with ulceration. Methods Patients presenting with tophi or ulceration(s) over tophi were prospectively recruited and their clinical characteristics were recorded. Comparison of clinical characteristics and risk factors for ulceration were analyzed between groups. Results A total of 105 patients were enrolled. 33 patients with ulcerations were older, with prolonged duration with gout and tophi, a higher rate of obesity, greater number of tophi, lower level of GFR, and higher level of serum creatinine, ESR and CRP. The mean duration of ulceration was 1.63 ± 2.32 months. The ulcerations mainly located in ankle (34.21%) and MTP (39.47%), with a mean size of 32.37 × 22.76 mm. The majority of ulcerations were categorized as stage I (42.4%) and stage II (51.5%). In univariate regression analysis, age, glucocorticoid abuse, gout duration, tophi duration, tophi number and GFR were associated with ulceration. In the multivariable model, significant differences were demonstrated in glucocorticoid abuse, tophi duration, tophi number. Conclusion Gout patients with ulceration(s) over tophi present several different aspects of clinical characteristics compared with those without ulceration. Glucocorticoid abuse, prolonged duration with tophi and greater number of tophi are risk factors for ulceration over tophi. Avoiding indiscriminate use of glucocorticoid needs to be emphasized, and prevention of tophi formation via initiate effective urate-lowering therapy is highly recommended in patients with gout. References [1] Lam G, Ross FL, Chiu ES. Nonhealing Ulcers in Patients with Tophaceous Gout: A Systematic Review. Adv Skin Wound Care. May2017;30(5):230-237. Disclosure of Interests None declared

Gouty tophus is an unusual cause of digital flexion contracture. Awareness of this pathophysiology will lead to more confidence in proper treatment and surgical management of this rare condition. This report describes a case of digital flexion contracture by tophaceous gout distinguished between trigger finger and locking of the metacarpophalangeal joint. We found the flexor tendon with a deposited chalky white substance suggestive of gouty tophus intraoperatively. We performed tenosynovectomy and removed the chalky white substance to the greatest degree possible. Histological findings confirmed the diagnosis of gout. Postoperatively, the patient recovered nearly to a full range of motion of the affected digits. When meeting with the patient who has had hyperuricemia and who is unable to extend the affected digits suddenly, one must keep in mind digital flexion contracture caused by tophaceous gout.

Gout is a common inflammatory arthropathy with a high prevalence worldwide. Increased levels of uric acid in the blood lead to deposition of monosodium urate crystals in the joints, inflammation, and pain. Acute gout attacks are often sudden, monoarticular, and typically resolve within a week, whereas chronic gout is often polyarticular with baseline pain between attacks. In chronic gout, depositions of uric acid known as tophi can form throughout the body. Despite the high prevalence of gout and the frequency with which tophi occur, ulceration over tophi is surprisingly rare. We report the case of a 38-year-old man, undiagnosed with gout, who presented to clinic for evaluation of ulcers with chalky white granules. The wounds were determined to be ulcerated tophaceous gout. Risk factors for ulceration over tophi and reported treatments are discussed.

The increase in serum urate concentrations (hyperuricaemia, ≥7.0mg/dL) creates crystals, which promote inflammation and joint lesions. Ultrasonography can reveal these urate deposits. The presence of crystals suggests that a patient with hyperuricaemia is actually experiencing asymptomatic gout, and that a patient with gout without subcutaneous tophi could experience tophaceous gout. The information offered by ultrasound (double contour sign and hyperechoic concretions mimicking clouds) enables a more specific classification of hyperuricaemia and gout. Additionally, this information can lead to relevant changes in terms of the diagnosis and therapeutic approach for patients with hyperuricaemia and gout.

Gout is the most treatable arthritis in the Western World—the pathophysiology of which is related to uric acid metabolism and there are effective medications available to treat both acute arthritis and chronic hyperuricemia. Despite this many patients continue to suffer from tophaceous gout with major detrimental effects on patient-reported outcomes and substantial economic impact. Poor adherence to medications is considered an important attribute in developing disability due to gout. This review summarizes recommendations from various national and international guidelines with an update on the therapeutics.

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 one of the most common inflammatory arthropathies. By searching a large administrative data base (Symphony Integrated Dataverse), we found that persons with acute gout see a rheumatologist infrequently, whereas less than 50% of advanced gout patients are seen by a rheumatologist. Notably, however, gout patients seen by rheumatologists have more frequent urate measurements and are prescribed urate lowering therapy more frequently. This study sought to determine whether involvement of a rheumatologist in gout care had a positive impact on health outcomesObjectives:To determine whether involvement of a rheumatologist had a positive impact on health outcomes of patients with gout.Methods:We carried out a retrospective analysis to identify persons with gout over an approximately 3-year period from October 2015 to December 2018. This study used data from the Truven Marketscan®database, an administrative database covering over 190 million patients across the United States and based on fully adjudicated and paid insurance claims. Patients were identified as having gout if they were >18 years of age and had at least two medical claims for the diagnosis of gout on different days, separated by at least 3 months. Patients with acute gout were identified by ICD-10 code M10.*, chronic nontophaceous gout (M1A.***0), tophaceous gout (M1A.***1) and uncontrolled gout (M10.*, M1A.*), the latter manifested by three gout codes (any) in the primary diagnosis position and three urate measurements within the same calendar year. Particular attention was placed on Emergency Room (ER) visits by individuals in each category and by individuals who had been evaluated by a rheumatologist.Results:We identified 284,877 gout patients. The median age was 59.2 years and 79.0% were male. Of the 230,998 persons coded as acute gout, 10.7% were seen by a rheumatologist, whereas 26.9% of the 32,942 coded as chronic nontophaceous gout, 47.2% of the 7,723 coded as tophaceous gout and 43.6% of the13,514 coded as uncontrolled gout were seen by a rheumatologist. In each gout category, the frequency of ER visits was significantly reduced in persons who had been seen by a rheumatologist (Table 1). In acute gout, the frequencies of ER visits in those with and without rheumatologist care were 5.6% vs 6.6% (pTable 1.Rheumatology BreakdownEmergency Room VisitsPopulationOverall NW/ RheumatologyPatients%With Gout ER Visit (%)p-value (comparing %)ER Visits* Per PatientAcute Gout230,698Yes24,63810.68%1373 (5.57%)1.47No206,06089.32%13632 (6.62%)1.53Non-Tophaceous Chronic32,942Yes8,86326.90%486 (5.48%)1.95No24,07973.10%1601 (6.65%)2.39Tophaceous Chronic7,723Yes3,64847.24%376 (10.31%)2.78No4,07552.76%597 (14.65%)2.89Uncontrolled13,514Yes5,88643.55%753 (12.79%)2.06No7,62856.45%1452 (19.04%)2.56* ER Visits are only included in this analysis if the primary diagnosis code on the claim is a gout code (M10.X, M1A.X)Conclusion:There appears to be a positive impact of rheumatologist involvement in the care of gout patients, manifested by a significant decrease in the frequency of ER visits. Considering the inconvenience and cost of ER visits, rheumatologist care may have a significant impact on the well-being of gout patients and on the overall cost of their care.Disclosure of Interests:Naomi Schlesinger Grant/research support from: Pfizer, Amgen, Consultant of: Novartis, Horizon Therapeutics, Selecta Biosciences, Olatec, IFM Therapeutics, Mallinckrodt Pharmaceuticals, N. Lawrence Edwards Consultant of: Horizon Therapeutics, Takeda Pharmaceuticals US, Aclaris Therapeutics, Atom Biosciences, Sanders Clark: None declared, Peter Lipsky Consultant of: Horizon Therapeutics

Gout is a metabolic disease that occurs either because of increased uric acid production or decreased uric acid secretion. It most commonly affects middle-aged to elderly men and postmenopausal women. Chronic tophaceous gout frequently occurs after 10 years or more of recurrent polyarticular gout. Gouty tophi are deposition of monosodium urate (MSU) crystals in and around joints as well as soft tissues. We present a case of chronic tophaceous gout in a 21-year-old male, which occurred after 4 years of onset of gouty arthritis. The patient presented with tophaceous gout in four forms, that is, periarticular subcutaneous tophi, disseminated intradermal tophi, ulcerative form, and miliarial tophi along with multiple sinuses discharging chalky white material. The case was diagnosed as chronic tophaceous gout on the basis of raised serum uric acid, imprint smear showing needle-shaped crystals and negatively birefringent crystals on polarized microscopy. The case is interesting for varied morphological forms of tophaceous gout in a patient at an early age and shorter interval between onset of gouty arthritis and tophaceous gout.

Background With the rising epidemic of gout, an increasing number of patients suffer from chronic ulcers associated with tophaceous gout in China, causing poor quality of life and disability. Such ulcers are very difficult conditions to deal with. Vacuum-assisted closure (VAC) has been proved to be effective in treating a variety kinds of wounds such as diabetic foot ulcers. However, its use in chronic ulcers associated with tophaceous gout has been seldom reported. Objectives In the present study, we evaluated the use of VAC in the treatment of chronic ulcers associated with tophaceous gout in comparison to conventional wound care (CWC). Methods We performed a 12 week prospective study that included 13 patients treated with VAC and 14 patients treated with CWC. We collected the clinical outcomes of these patients and data from a satisfaction survey. Chronic ulcers were treated until wound closure, or until the end of 12 weeks. Study will discontinue when the ulcer worsens or remains unchanged by the end of week 4. Results Granulation tissue appeared in 12 (92.31%) patients by the end of week 2 in the VAC group, while it appeared in 6 (42.86%) patients by that time in the CWC group (p=0.013). 100% granulation was achieved in 11 (84.62%) patients by the end of week 8 in the VAC group as compared to 5 (35.71%) patients by that time in the CWC group (p=0.018). By the end of week 12, decreasing in wound size was achieved in 12 (92.31%) patients in the VAC group, while it was achieved in 10 (71.43%) patients in the CWC group (p=0.326). Among them, wound closure was achieved in 9 (69.23%) patients in the VAC group, while it was achieved in 3 (21.43%) patients in the CWC group (p=0.021). None developed local infection in both groups during the treatment. More patients in the VAC group were satisfied with treatment as compared to the CWC group. Conclusions Our preliminary study suggests that VAC therapy is effective and safe in treating chronic ulcers associated with tophaceous gout and appears to be superior to CWC therapy. Large-scale studies are needed to further evaluated the efficacy and safety of the VAC therapy in the treatment of chronic ulcers associated with tophaceous gout. Reference [1] Agarwal J, Ogilvie ML, Lohman R, et al. Vacuum-assisted closure for sternal wounds: a first-line therapeutic management approach. [J]. Plastic & Reconstructive Surgery2015;116(4):1035–1040. Acknowledgements We are grateful to all the participants in our study. Disclosure of Interest None declared

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.

We report the case of a 31-year-old male whose initial imaging presentation was considered highly suspicious for an edematous accessory muscle, the anconeus epitrochlearis. Operative excision led to the diagnosis of tophaceous gout. If this etiology had been considered earlier in the patient's clinical course, his diagnostic evaluation may have been less involved. When faced with a soft tissue mass in the setting of gout, a soft tissue tophus should always be considered.

Background/Purpose Carpal tunnel syndrome caused by gout is rare. We presented our experience in treating these patients. Methods We conducted a retrospective review of cases treated from 2010 to 2013. Eight patients were identified out of 348 carpal tunnel releases performed. Results All patients were male. All patients had gouty tophi on the same hand and other locations on the body. Open carpal tunnel release was performed on all patients. There was gouty tenosynovitis in all patients but no encasement of the median nerve. The mean follow-up was 16 months. Numbness improved in seven out of eight patients. Conclusion Gout should be considered a cause of carpal tunnel syndrome, particularly in patient with a history of gout. Early surgical outcome is promising. Longer follow-up is needed to detect recurrence.

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.

Fractures in the sesamoid bones may occur by direct trauma or repetitive overuse (stress fractures). Acute fracture of the hallucal sesamoids is seen most often with dislocation of the metatarsophalangeal joint after a high-energy injury1. A chronic stress fracture of the sesamoid bone is generally found in athletes and can be difficult to differentiate from other conditions that affect the hallucal sesamoids2. The optimal choice of treatment remains unclear3. In chronic tophaceous gout, urate deposition may occur in articular cartilage, subchondral membranes, joint capsules, and periarticular tissues. An isolated intraosseous tophaceous lesion in the hallucal sesamoids is rare4-7. We found only one previously published report describing a chronic stress fracture and nonunion of a hallucal sesamoid that was associated with tophaceous gout8. To our knowledge, there have been no previously published reports of an acute comminuted pathologic fracture of a hallucal sesamoid with a tophaceous deposit. We describe a rare case of an acute comminuted pathologic fracture with tophus of the fibular sesamoid in a young soldier with no history of gout or underlying systemic disorder. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A twenty-year-old soldier with no history of gout noted a painful disability of the right forefoot during a military march. The pain persisted for several days, and he was not able to bear weight in the standing position. He noted that he had experienced similar forefoot pain three years prior; he had also experienced similar symptoms several times before, but with less intensity. The pain increased during forced dorsiflexion of the …

In this case, we present a patient with the diagnosis of bilateral olecranon tophaceous gout. After the surgical treatment, there was no limitation of range of motion or wound problem at 6th month control.

Diagnosis of gouty arthritis in the elderly may be complicated due to its different clinical course as compared to younger age groups. Clinical observation of gout in elderly patients has revealed the following differentiating signs

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.

Study Design Case report. Objective The objective of this study is to report the occurrence of tophaceous gout in the lumbar spine. Methods Using a case report to illustrate the key points of gout in the spine, we provide a brief review of gout in the literature as it relates to its orthopedic and spinal manifestations as well as guidelines for management. Results This case report details the occurrence of a large and clinically significant finding of tophaceous gout in the lumbar spine in a 24-year-old man with a known history of gout and a 3-year history of progressive back pain. Conclusion A high index of suspicion can assist in diagnosis of patients presenting with back pain or neurologic findings with a history of gout. A previous history of gout (especially the presence of tophi), hyperuricemia, and the radiological characteristics presented here should aid the clinician in making the diagnosis of spinal gout. Early diagnosis has the potential to prevent the need for surgical intervention.

Objective: The study aim is to present the clinical, radiological aspects and treatment of this disease from the neurosurgical standpoint using a literature review and an illustrative case. Methods: A PubMed research was done with the terms “tophaceous gout”, “spine”, and “diagnosis”. We reviewed these articles and compared it with an illustrative case here presented. Results: According to a research done, this is the fifty-second case of tophaceous gout of the spine described in the English literature. The case and literature review presented demonstrate the difficulty in diagnosis, especially when the patient has no previous history of gout. Conclusion: It is important to consider tophaceous gout of the spine among the differential diagnoses that occur in the spine. Clinical and neurosurgical treatment may be required considering each case.

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.

The association of chronic tophaceous gout with severe hypercalcaemia is exceptional. In this case, a 42-year old man with a longstanding history of gout arrived at the emergency room with altered mental status. Laboratory work up revealed a uric acid of 14.0 mg/dl, corrected calcium of 14.5 mg/dl, phosphorous of 6.3 mg/dl, parathyroid hormone (PTH) was suppressed (

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.