Tophaceous gout

An 82-year-old male with heart failure with reduced ejection fraction, chronic kidney disease, and gout presented with volume overload. Examination of his right elbow revealed a large, firm, painless, multilobulated nodule that did not transilluminate (Figures 1 and 2). Multiple small, firm subcutaneous nodules scattered across both extremities consistent with gouty tophi (Figure 3) were also present. He first experienced podagra 20 years prior and preferred using lime juice to treat his frequent gout flares. His tophi had slowly grown over that period. A serum uric acid level returned elevated at 11.6 mg/dL. On discharge he resumed allopurinol and colchicine with eventual improvement in his symptoms.

Tophi are deposits of monosodium urate accompanied by chronic granulomatous inflammatory changes in the surrounding tissue.¹ While often located around appendicular skeletal joints, tophi may locate in other soft tissue structures including the ears, bursae, tendons, and axial skeleton.^{1, 2} Tophi are associated with longstanding gout and poorly controlled levels of urate.^{1, 2} They are typically firm and painless but can begin to soften with the initiation of urate-lowering therapy and may periodically experience acute inflammation leading to pain.² Tophi are often variable in size and location may lead to misdiagnosis as nodules of rheumatoid arthritis or Heberden's nodes of osteoarthritis.

The authors declare no conflicts of interest.