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Year : 2014  |  Volume : 1  |  Issue : 2  |  Page : 128-129

Tophi: A pointer towards the diagnosis of gout


1 Department of Medicine, Christian Medical College, Ludhiana, Punjab, India
2 Department of Pathology, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication11-Jun-2014

Correspondence Address:
Jency Maria Koshy
Department of Medicine, Christian Medical College, Ludhiana, Punjab 141 008
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.134283

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  Abstract 

Tophi are deposits of monosodium crystals in people with long-standing gout. We report a case of a 34-year-old male presenting with joint pains and soft yellowish swelling over the web spaces of the toes. Aspiration of the same revealed monosodium crystals leading to a diagnosis of Tophaceous gout.

Keywords: Gout, monosodium crystals, tophi


How to cite this article:
Koshy JM, John M, Kaur R, Solomon L. Tophi: A pointer towards the diagnosis of gout. CHRISMED J Health Res 2014;1:128-9

How to cite this URL:
Koshy JM, John M, Kaur R, Solomon L. Tophi: A pointer towards the diagnosis of gout. CHRISMED J Health Res [serial online] 2014 [cited 2020 Jul 11];1:128-9. Available from: http://www.cjhr.org/text.asp?2014/1/2/128/134283

A 34-year-old male presented with joint pains for two years worsening over six months prior to the presentation. The sequence of involvement was small joints of hands followed by wrist, elbow, and both shoulders with a history of morning stiffness. Examination revealed dactylitis of middle and ring finger bilaterally. Soft yellowish fluctuant swellings were noted in the web spaces of first and second toes of the right foot [Figure 1] and the dorsal aspect of the left third toe [Figure 2].
Figure 1: Yellowish fl uctuant swelling in the web spaces of fi rst and second toes of the right foot

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Figure 2: Soft swelling in the dorsal aspect of the left third toe

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Aspirate revealed bright needle-like negatively birefringent monosodium urate crystals under polarized microscope and on Gram stain [Figure 3] and [Figure 4] leading to a diagnosis of Tophaceous gout. Abnormal laboratory investigations included 2 mg/dl serum creatinine, 8.5 g/dl hemoglobin, 15, 200/mm 3 total leukocyte count, and 11.7 mg/dl serum uric acid. Fractional excretion of uric acid was 1.08 (>0.7) suggesting an overproducer. Abdominal ultrasonography revealed nephrolithiasis. He was managed with analgesics during the acute phase and was initiated on the xanthine inhibitor, allopurinol on follow up.
Figure 3: Field packed with bright needle like negatively birefringent monosodium urate crystals under polarized microscope

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Figure 4: Gram staining depicting monosodium crystals

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  Discussion Top


Tophi are deposits of monosodium crystals in people with long-standing gout. Decreased creatinine clearance in gout is associated with early presentation with tophi. [1] The tophaceous deposits accumulate around the joints of the feet, fingers, joints, elbows, Achilles' tendon, pinna of the ear, within olecranon bursa, or prepatellar bursa. Chronic tophaceous gout can mimic chronic rheumatoid arthritis with rheumatoid nodules. [2] Other differentials to be considered are rheumatoid nodules, nodal osteoarthritis, psoriatic arthritis, or scleroderma. Persistently high uric acid level can lead to urolithiasis or urate nephropathy, [3] as in this case.

 
  References Top

1.Dalbeth N, House ME, Horne A, Taylor WJ. Reduced creatinine clearance is associated with early development of subcutaneous tophi in people with gout. BMC Musculoskelet Disord 2013;14:363.  Back to cited text no. 1
    
2.Rott KT, Agudelo CA. Gout. JAMA 2003;289:2857-60.  Back to cited text no. 2
    
3.Philip J. Crystal induced arthropathies. In: Pispathi K, editor. Manual of Rheumatology. 2 nd ed. Mumbai: Indian Rheumatology Assoc; 2002. p. 130-50.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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