A 52-year-old man with chronic tophaceous gout was evaluated at our facility. His disease began more than 10 years ago with acute arthritis in his hands and feet with asymmetric distribution. He received irregular treatment with allopurinol. Physical examination revealed multiple solid, tender and enlarged intradermal and subcutaneous nodules located in the hands, feet, elbows, legs, buttocks and abdominal wall, either in periarticular structures or in sites distant to articular structures (figs 1 and 2). Analysis of the tophi content by compensated polarised light microscopy revealed intracellular needle-shaped crystals that were negatively birefringent, consistent with monosodium urate.

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Figure 1

Nodules located in the hands, elbows, legs, buttocks and abdominal wall (arrows).

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Figure 2

Nodules in periarticular structures and arthritis only in few joints.

Typically, gout has four phases including asymptomatic hyperuricaemia, acute gouty arthritis, intercritical gout and chronic tophaceous gout. These manifestations can occur in any combination or alone.1 Chronic tophaceous gout frequently occurs after 10 years or more of recurrent polyarticular gout. Tophi can occur in soft tissue, osseous tissues, ligaments and different organs and either in presence or absence of gouty arthritis.2 The involved joints are persistently painful and swollen, and sometimes with a symmetrical partner that can occasionally be confused with rheumatoid arthritis. The treatment for chronic tophaceous gout with glucocorticoids or colchicine has been described as effective in some patients, but no other established therapy is available.2

Although the prevalence of thophaceous gout, principally the generalised form of it, has decreased in the past years, the disease still exists likely due to the absence of an accurate diagnosis and therapy.