Bilateral Nodules of the Hands and Feet
Answer: D. Tophaceous gout
Tophaceous gout is characterized by the presence of tophi in the joints, which are accumulations of monosodium urate crystals that manifest in tissue with poor blood supply. Tophi accumulation can lead to skin ulceration and, in some cases, rupturing of the skin and discharge of urate crystals, which manifests in the form of a white-flecked chalky substance visible upon examination.1 Tophaceous gout is diagnosed clinically in patients with elevated serum uric acid levels and usually manifests in patients who have a history of uncontrolled gout for 10 or more years.
Urate-lowering therapies are used in disease management in patients with a history of gout. Serum urate levels should be lowered to less than 6.0 mg/dL.2
Osteoarthritis can be ruled out in this patient because the characteristic Heberden and Bouchard nodes are smaller than tophi. Additionally, osteoarthritis is noted more in the distal interphalangeal and proximal interphalangeal joints. Joint aspirate in osteoarthritis does not show crystals.3
Rheumatoid arthritis is destructive to the joints without crystal deposition, and swan-neck deformities of the joints are characteristic of a diagnosis of chronic rheumatoid arthritis in the setting of inflammatory disease—neither of which were found in this patient.4 The absence of morning stiffness also excludes the diagnosis of RA.5
The patient does not have septic arthritis, which is characterized by painful, hot joints and is acute, not chronic, in nature.6
Patient Outcome and Follow-Up
The patient was given febuxostat, 40 mg/d and sent home once his symptoms were alleviated. The patient was scheduled for follow-up with a rheumatologist once every 3 months following.
1. Harris MD, Siegel LB, Alloway JA. Gout and hyperuricemia. Am Fam Physician. 1999;59(4):925-934. https://www.aafp.org/pubs/afp/issues/1999/0215/p925.html
2. FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care Res (Hoboken). 2020;72(6):744-760. doi:10.1002/acr.24180
3. Hinton, Ralph, et al. “Osteoarthritis: Diagnosis and Therapeutic Considerations.” Am Fam Physician. 2002;65(5):841-849 https://www.aafp.org/pubs/afp/issues/2002/0301/p841.html
4. Lane R, Nallamothu SV. Swan-Neck Deformity. In: StatPearls [Internet]. StatPearls Publishing; April 30, 2022. https://www.ncbi.nlm.nih.gov/books/NBK525970/
5. Taylor PC. Update on the diagnosis and management of early rheumatoid arthritis. Clin Med (Lond). 2020;20(6):561-564. doi:10.7861/clinmed.2020-0727
6. Long B, Koyfman A, Gottlieb M. Evaluation and management of septic arthritis and its mimics in the emergency department. West J Emerg Med. 2019;20(2):331-341. doi:10.5811/westjem.2018.10.4097