This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

A Beutler

A So

AB Garrod

Abhijeet Dhoble

AP Hall

EW Campion

GF Falasca

HR Schumacher

JA Logan

P Hollingworth

PA Simkin

R Wernick

Robert Smith

S Sutaria

SE Malawista

SL Wallace

TP Gordon

Vijay Balakrishnan

W Urano

W Zhang

English

PubMed

Crossref

Chronic tophaceous gout presenting as acute arthritis during an acute illness: a case report

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BioMed CentralCases Journal
ssOpen AcceCase Report
Chronic tophaceous gout presenting as acute arthritis during an 
acute illness: a case report
Abhijeet Dhoble*, Vijay Balakrishnan and Robert Smith
Address: Department of Internal Medicine, Michigan State University, East Lansing, Michigan, USA
Email: Abhijeet Dhoble* - abhijeetdhoble@gmail.com; Vijay Balakrishnan - vijaybabu@yahoo.com; Robert Smith - robert.smith@hc.msu.edu
* Corresponding author    
Abstract
Background: Gout is a metabolic disease that can manifest as acute or chronic arthritis, and
deposition of urate crystals in connective tissue and kidneys. It can either manifest as acute arthritis
or chronic tophaceous gout.
Case presentation: We present a 39-year-old male patient who developed acute arthritis during
his hospital course. Later on, after a careful physical examination, patient was found to have chronic
tophaceous gout. The acute episode was successfully treated with colchicines and indomethacin.
Conclusion: Gout usually flares up during an acute illness, and should be considered while
evaluating acute mono articular arthritis. Rarely, it can also present with tophi as an initial
manifestation.
Background
Gout is a metabolic disease, which is characterized by
acute or chronic arthritis, and deposition of monosodium
urate crystals in joint, bones, soft tissues, and kidneys [1-
4]. In 18th century, Garrod proposed a causative relation-
ship between elevated uric acid and urate crystal forma-
tion, which is underlying pathology for gout [4]. Gout can
either manifest as acute arthritis or chronic arthropathy,
which is also called tophaceous gout [1,2,5].
Case presentation
A 39-year-old African American male patient was admit-
ted with one-day history of acute left lower quadrant pain,
and was diagnosed with acute uncomplicated diverticuli-
tis, confirmed by computed tomography (CT) of the
abdomen. His medical and surgical history was unre-
markable, and he denied any medication use. He denied
smoking or illicit drug use, but admitted occasional alco-
hol use on every other weekend. He did not follow any
particular diet. He had an average built with BMI of 29.6.
He was started on intravenous antibiotics and pain medi-
cation, which led to significant clinical improvement
within two days.
On the third day of hospitalization, he developed acute,
severe pain and swelling of the left elbow. Within next few
hours, pain worsened and he was unable to move the
elbow joint, which was tender, erythematous, and swollen
on examination (figure 1). Never investigated in the past,
we also noted a firm 4 × 6 cm mass on each elbow, and
another one surrounding the proximal inter-phalangeal
joint of right middle finger (figure 2). There was no over-
lying edema or cellulitis. There were no other swellings or
tophi noted especially on toes or ears. When asked partic-
ularly, he denied similar episodes in the past. He also
denied any episode of swelling of great toe in the past.
Published: 15 October 2008
Cases Journal 2008, 1:238 doi:10.1186/1757-1626-1-238
Received: 9 October 2008
Accepted: 15 October 2008
This article is available from: http://www.casesjournal.com/content/1/1/238
© 2008 Dhoble et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:238 http://www.casesjournal.com/content/1/1/238Plain radiography of left elbow showed joint effusion,
and soft tissue swelling. Radiography of other joints
including hands and feet was not performed. Laboratory
values on the third day are given in table 1. Liver function
test was also performed, and the results were unremarka-
ble. Diagnostic arthocentesis was performed on both the
elbows, and revealed negatively birefringent needle-
shaped crystals using polarized microscopy in both sam-
ples. Detailed analysis of synovial fluid is given in table 2.
The swelling on the right elbow was aspirated to deter-
mine the etiology because patient had that swelling for a
long time.
The patient responded partially to colchicine, but later
had great relief with indomethacin. Colchicine was used
at the dose of 0.6 mg every two hourly. He received total
of six doses, but it was stopped because he developed
severe nausea and vomiting. He admitted that his pain
was reduced to 4/10 in intensity from 9/10 before treat-
ment, but swelling was persistent. We initiated indometh-
acin at 50 mg every eight hourly, and his pain and
swelling was relieved to great extent in 48 hours.
Discussion
Gout is a metabolic disease that can manifest as acute or
chronic arthritis, and deposition of urate crystals in con-
nective tissue and kidneys. All patients have hyperuri-
cemia at some point of their disease. But, either normal or
low serum uric acid levels can occur at the time of acute
attack; and asymptomatic hyperuricemic individuals may
never experience a clinical event resulting from urate crys-
tal deposition [1-4]. Low to normal uric acid concentra-
Tophus at the back of right elbowFigure 1
Tophus at the back of right elbow. Tophi/tophus around the proximal inter-phalangeal joint of right middle fingerFigure 2
Tophi/tophus around the proximal inter-phalangeal 
joint of right middle finger.
Table 1: Laboratory values at admission.
Test Value Value range
Sodium 139 meq/l 135–145
Potassium 3.5 meq/l 3.5–4.9
Chloride 108 meq/l 96–110
CO2 28 mmol/l 20–30
BUN 18 mg/dl 6.0–23.0
Creatnine 0.7 mg/dl 0.6–1.4
Total protein 5.4 g/dl 6.0–8.0
Albumin 3.4 g/dl 3.6–5.0
Magnesium 1.6 meq/l 1.3–2.2
Phosphorus 3.3 mg/dl 2.5–4.5
Calcium 8.2 mg/dl 8.0–10.5
White blood count 12,400/mm3 4–12
Hemoglobin 11.6 g/dl 12.6–16.5
Platelet count 133 000/mm3 150–400
Uric acid 6.8 mg/dL 3.4–7.0Page 2 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:238 http://www.casesjournal.com/content/1/1/238tion can be due to excessive excretion of uric acid, crystal
formation, or systemic inflammatory state [6,7]; however,
exact mechanism is still not completely understood. A
diagnosis of gout is most accurate when supported by vis-
ualization of uric acid crystals in a sample of joint or bur-
sal fluid, or demonstrated histologically in excised tissue.
Synovial fluid analysis of our patient was consistent with
inflammatory arthritis. Mild leucocytosis in this patient
was due to systemic inflammatory response.
Visible or palpable tophi, as this patient exhibited, are
usually noted only among those patients who are hyperu-
ricemic and have had repeated attacks of acute gout, often
over many years. However, presentation of tophaceous
deposits in the absence of gouty arthritis is also reported
[5,8]. Pain and inflammation are manifested when uric
acid crystals activate the humoral and cellular inflamma-
tory processes [9].
During an acute illness, if systemic inflammatory state
prevails, such as in an acute infection, cytokines and
chemokines triggers inflammation and cause arthritis in
the presence of urate crystals [10,11]. Phagocytosis of
these crystals by macrophages in the synovial lining cells
precedes influx of neutrophils in the joint [9-11]. This
process releases various mediators of inflammation
locally [12,13].
Hyperuricemia is often present in patients with topha-
ceous gout, and they can benefit from uric acid lowering
therapy early during the course [14,15]. In our patient,
serum uric acid and 24-hour urine uric acid level was
within normal limits when measured in the hospital
before his discharge from the hospital. It was decided to
follow him up in the clinic in two weeks, and measure
these values again during 'interval gout' before deciding to
start him on any particular medication to prevent further
attacks of acute arthritis.
Our patient presented with tophi as an initial presentation
of gout, which is very rare, but has been reported [5,8].
Investigational studies due to acute elbow joint pain deci-
phered the underlying mystery of chronic swelling. Sys-
temic inflammatory response secondary to diverticulitis
exposed the joints to the effects of urate.
First-line treatments for an acute flare are either oral col-
chicine and/or non-steroidal anti-inflammatory agents.
Systemic or intra-articular corticosteroids can also be
used, and are equally effective, but with more side effects
[16,17]. Interleukin-1 inhibitors are still under investiga-
tion, and are not approved for an acute attack of gout [18].
Conclusion
Gout usually flares up during an acute illness, and should
always be considered while evaluating acute mono articu-
lar arthritis in hospitalized patients. Gout can present
with tophi as an initial manifestation of the disease proc-
ess.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors contributed equally in collecting patient data,
chart review, and editing medical images. All authors read
and approved the final manuscript.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images in Journal of Medical Case Reports. A copy of the
written consent is available for review by the Editor-in-
Chief of this journal.
Acknowledgements
We thank patient for giving us consent for the publication of the case 
report.
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Tophi as the initial manifestation of gout. Report of six cases and review of literature. Arch intern med

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2572609

Chronic tophaceous gout presenting as acute arthritis during an acute illness: a case report

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