Gouty tophi.

Gouty tophi presenting as multiple large periarticular masses could be mistaken for rheumatoid nodules, neoplasm, neurofibroma, or infection. Aspiration of synovial fluid from inflamed joints or examination of whitish material expressed though breaks in skin usually assists with the diagnosis of gout.

Case report

A 59-year-old male presented with painful swelling of his hands and knees and subjective fever over the preceding few days. The pain affected joints of hands and knees and was aggravated by a range of motion. The patient was afebrile and appeared well. Numerous tender subcutaneous nodules were noted on examination of his hands (shown in the Fig. 1) and prepatellar areas. These nodules were tender and warm. Irregular whitish material was seen through the thin and distended skin. Uric acid was elevated to 9.7 mg/dl, and creatinine to 1.5 mg/dl. Negatively birefringent crystals of monosodium urate were present in the joint fluid. The patient was diagnosed with polyarticular tophaceous gout and started on allopurinol.

Fig. 1

Gouty tophi.

Gouty tophi presenting as multiple large periarticular masses could be mistaken for rheumatoid nodules, neoplasm (1, 2), neurofibromata (3), or infection. Aspiration of synovial fluid from inflamed joints or examination of whitish material expressed though breaks in the skin usually assists with a diagnosis of gout (1). However, in cases as shown here, the appearance of the tophi is pathognomonic for gout. Aspiration may still be needed for exclusion of concomitant infection and ‘de-bulking’ of inflamed joints to expedite healing.