Chronic Tophaceous Gout

This would be a short case discussion. 

This case is a male patient with multiple joint swellings affecting both upper limbs. The swellings seem to affect the DIPJ, MCPJ as well as wrists. What is also strikingly noticeable is the presence of multiple tophi over the joint swellings. It is not difficult to reach a conclusion of tophaceous gout. 

Tophi are usually found occuring over distal joints or tissues where temperatures are relatively "cooler". This will enable cystallization to occur. This tophi are usually found over distal finger or toe joints, ear pinna. In severe cases, tophi can even be found ocurring almost anywhere on the body as depicted above. 

The next step would be to look for the possible aetiology. Look for psoriatic rashes, polycythemia, hepatosplenomegaly and lymphadenopathies to suggest hematological malignancies.

Then, last but not least, look for complications of the disease itself. Look for sallow coloured skin, dialysis catheters, arteriovenous fistulas to suggest chronic kidney or end stage kidney disease either as a result of obstructive uropathy or chronic NSAID intake for gouty pains. Examine the abdomen for enlarged ballotable kidneys to suggest obstructive uropathy due to urolithiasis. Also look for complications of chronic steroid therapy e.g. Cushing syndrome, hypertension, hyperglycemia (many GP clinics prescribe steroids and NSAIDs to control gouty arthritic pains). 

Remember to apply the triad of diagnosis - aetiology - complications for any case you encounter regardless of short or long case examination. This guide will serve you well and assist you in approaching any case as complete as possible. 

The image above shows central obesity with striation over the anterior abdomen suggesting a Cushingoid appearance. Take note also that there are multiple hyperpigmented scars over the peri-umbilical region suggesting repeated injections likely insulin therapy thus suggesting this patient may have concomitant diabetes mellitus. This will further strengthen the suspicion of Cushing's syndrome. Also notice that there are multiple tophi over the anterior abdominal wall as well. 

Therefore it can be concluded that this patient has been suffering from chronic tophaceous gout for which he has been treated with chronic steroid therapy resulting in secondary Cushing's syndrome. 

Should this case appear for the examinations, the case can be approached from the aspect of gout or can be approached from the aspect of Cushing's syndrome from which the diagnosis of gout is expected to be offered as the underlying main problem. So students should be ready for any possibilities. 

For the long case examination involving a patient with gout, it would be sensible to approach gout from this perspective: 

Gout is due to hyperuricemia.

Hyperuricemia can accumulate due to increased production or decreased clearance. 

For increased production, ask about dietary purine intake, ask about lifestyle (alcohol), ask about cell hemolysis (can be from polycythemia, can be from large solid tumours, can be from hemolytic anemia), ask about tissue damage (burns, surgery, trauma) and last but not least genetic factors (so ask about family history). 

For decreased clearance, ask about dehydration, ask about medications e.g. ACE inhibitors or ARBs or diuretics or aspirin which impedes uric acid excretion and ask about underlying kidney diseases.

Lastly remember to apply the triad of diagnosis - aetiology - complications as well to make your history complete. 

CCE.