Chronic Tophaceous Gout

Summary of history and examination

A 48 year old chinese gentleman from Muar working as a driver, presented to the Medical OPD with bilateral pedal edema for the duration of 1 week and shortness of breath for 1 week. The shortness of breath is associated with cough which produces whitish sputum. There is no fever, chest pain or palpitations. There is no orthopnea or PND. His bowel and bladder habits are regular. There is no loss of weight or loss of appetite.

He has been a smoker for 20 pack years and has been having gout over the last 20 years. He is not compliant with his medication and does not control his diet.

On examination, his pulse is 92 beats/min, his BP is 120/74 mmHg, respiratory rate is 24 breaths/min and his temperature is 37 degrees celcius. There is anemia seen in the palm and conjunctiva.

He has numerous hard swellings over his 2, 3 and 5th fingers on the left hand at the distal interphalangeal joint, a swelling at the 2nd finger at the metacarpophalangeal joint and swellings over the elbow at both hands. There are also swellings at the feet over the large toes on both sides. The swellings are irregular, non-tender, hard with no discharge. There are some whitish deposits seen over the swellings. They measure 2x3cm on the hands and feet and 5x8cm on the elbows. There is also Swan neck deformity of the 2nd finger and Boutonniere deformity of the 4 finger on the left hand.

Examination of the lungs revealed bibasal crepitations. Cardiovascular and abdominal system were normal.

Chest X-ray showed lower zone haziness with loss of costophrenic angles on both sides and cardiomegaly.

Investigations

FBC :

• Hb - 10.7 g/dl
• MCH - 26.8pg
• Platelets - 217 x 10^3 U/L
• TWBC - 9.31 x 10^3 U/L

Renal Profile :

• Serum creatinine - 109 U/L
• Uric Acid - 681 micromol/L
• Urea - 6.3 mmol/L
• Sodium - 135 mmol/L
• Potassium 3.1 mmol/L
• Chloride - 102 mmol/L

Liver Profile :

• Total protein - 65 g/L
• Albumin - 30 g/L
• Globulin - 35 g/L
• A/G ratio - 0.9
• Total bilirubin - 37 micromol/L
• ALP - 119 U/L
• ALT - 296 U/L

Cardiac Enzymes :

• Creatinine Kinase - 168 U/L
• LDH - 794 U/L
• Aspartate transaminase - 79 U/L
• Calcium - 2.14 mmol/L

Random Glucose :

• 5.6mmol/L

Impression :

• Congestive Cardiac Failure and Chronic Tophaceous Gout with Renal Impairment.

Discussion on Chronic Tophaceous Gout:

• On examination, it is important to look at other sites where nodules can appear, extensor surfaces, hands, forearm, elbows, Achilles tendons and helix of the ear.

• Although tophi are usually a late feature, they can appear over a year if there is chronic renal failure. (This patient mentioned that there had been development of new nodules around his hand over the past year.)

• The first joint involved are usually the first metatarsophalangeal joint.

• Definite confirmation of diagnosis is by identification of monosodium urate monohydrate (MSUM) crystals in the aspirate from the nodules.

• Apart from hyperuricemia, other risk factors and interrelated associations for primary gout include:

1. obesity
2. high alcohol (predominantly beer)
3. type IV hyperlipidemia, hypertension and IHD

• Management

Acute Attack:

1. Oral NSAID's (diclofenac) for pain relief
2. Oral colchcine (1 mg loading dose then 0.5 mg 6 hourly till symptoms abate)

Long-term Management:

1. Lifestlye alteration, correct obesity and reduce beer consumption.
2. Allopurinol (100-300 mg/day)
3. Measure serum uric acid levels every 6 weeks and adjust drug dosage appropriately.