Multiple Subcutaneous Gouty Tophi Even with Appropriate Medical Treatment: Case Report and Review of Literature

Abstract

INTRODUCTIONGout is one of the most common and complex causes of arthritis that can affect anyone. 1,2 It is one of the most ancient medical conditions known going back to references in Egypt in 2640 BC and Hippocrates writing about it in 400 BC. [3][4][5] Gout occurs when there are deposits of urate monosodium crystals in the synovial fluid and other tissues causing the inflammation and intense pain of a gout attack. Urate monosodium crystals usually are associated with longterm hyperuricemia that is triggered by several genetic factors as well as environmental factors such as the overconsumption of rich purine diets, alcohol, obesity, obesity-related disease, kidney disease, and certain medications. 1,[6][7][8][9][10][11][12][13] Risk factors for older patients include lowdose aspirin, alcohol abuse, decreased renal function, and prolonged use of diuretics. 14,15 Advanced gout, also known as gouty tophi, are large, visible (masses) made up of urate crystals. 5,16,17 The tophus is a cardinal sign and usually develops after 5-10 years of chronic undertreated gout with the olecranon bursa being one of the most affected areas. 5,16,17 Formation is caused by elevated serum uric acid levels due to neglected and poorly controlled gout. 18,19 Gouty tophi can develop anywhere. It can develop in periarticular soft tissues, sub-articular regions around bones, tendon sheaths, bursas, articular cartilage, and synovial tissues around flexor tendons. 17,20 Gouty tophi have been identified in vocal cords, myocardium, heart valves, eyes, spinal cord, pancreatic tail, breast, penis, with a propensity to affect the helix of the ear. 17,21,22 However, patients with multiple gouty tophi rarely are encountered because hyperuricemia can be treated effectively. The differential diagnosis of gouty tophi is broad, even though gout can be diagnosed clinically by elevated serum uric acid level; however, the concentration of serum uric acid may be within the normal limits and yet gouty tophi still can be developed. [23][24][25] This case was a patient who developed multiple gouty tophi over an extended period of time with increasing size of the masses while on medical treatment for his gout. The one mass of unique interest developed over the superficial anterior tibia just distal to the tibial tubercle and not in the patellar tendon, which is uncommon.