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Gout Flare With a Draining Tophus

  • Adam B. Wallace and William Johnson
Published/Copyright: June 1, 2016
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Journal of Osteopathic Medicine
From the journal Journal of Osteopathic Medicine Volume 116 Issue 6

A 90-year-old woman with a history of stage-3 chronic kidney disease, hypertension, and gout presented with chills and severe pain in the first toe on the left foot. Physical examination revealed large, firm nodules bilaterally on her metatarsophalangeal joints. The metatarsophalangeal joint on the left foot was abraded and draining a chalky white substance (panel A). Plain radiographs and magnetic resonance images were consistent with tophaceous gout and acute osteomyelitis (panel B). A blood culture was positive for methicillin-sensitive Staphylococcus aureus. The patient had no other stigmata of endocarditis, and echocardiography results showed no vegetations. The patient underwent partial first ray amputation on the left foot. Histologic findings confirmed the diagnosis of chronic tophaceous gout complicated by acute osteomyelitis. Her surgical margins were clear of infection. Intravenous antibiotics were administered, and she was discharged to home 3 days after the operation.

Chronic tophaceous gout is rarely encountered in modern medicine. Complications include bone destruction, joint deformities, and, as in the present case, secondary infections. Diagnosis can be made on clinical grounds and confirmed with the visualization of uric acid crystals under light microscopy. The American College of Rheumatology recommends urate-lowering therapy in all cases of tophaceous gout.

From the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania (Student Doctor Wallace), and the Lankenau Medical Center in Wynnewood, Pennsylvania (Dr Johnson).

*Address correspondence to Adam B. Wallace, MS III, 248 S 11th St, Apt 1, Philadelphia, PA 19107-6745. E-mail:

Acknowledgment

We thank Ryan C. Miller, DO, for his assistance with radiologic imaging.

Suggested Reading

1. Khanna D ,FitzgeraldJD,KhannaPP, et al. 2012 American College of Rheumatology guidelines for management of gout, part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012;64(10):1431-1446. doi:10.1002/acr.21772.10.1002/acr.21772Search in Google Scholar PubMed PubMed Central

2. Khanna D ,KhannaPP,FitzgeraldJD, et al.2012 American College of Rheumatology guidelines for management of gout, part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis.Arthritis Care Res (Hoboken).2012:64(10):1447-1461. doi:10.1002/acr.21773.10.1002/acr.21773Search in Google Scholar PubMed PubMed Central

Accepted: 2015-11-23
Published Online: 2016-06-01
Published in Print: 2016-06-01

© 2016 American Osteopathic Association

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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https://doi.org/10.7556/jaoa.2016.083
Creative Commons
BY-NC-ND 4.0

Articles in the same Issue

  1. AOA COMMUNICATION
  2. Official Call: 2016 Annual Business Meeting of the American Osteopathic Association
  3. Proposed Amendments to the AOA Constitution, Bylaws, and Code of Ethics
  4. ORIGINAL CONTRIBUTION
  5. Glycated Hemoglobin Testing to Identify Undiagnosed Diabetes Mellitus in the Inpatient Setting
  6. Correlation of Somatic Dysfunction With Gastrointestinal Endoscopic Findings: An Observational Study
  7. BRIEF REPORT
  8. Cancer Mortality Trends in Medically Underserved Counties in Virginia
  9. REVIEW
  10. Comprehensive Evaluation for Obesity: Beyond Body Mass Index
  11. MEDICAL EDUCATION
  12. Ten Tips for Maximizing the Effectiveness of Emergency Medicine Procedure Laboratories
  13. Osteopathic Manipulative Treatment Technique Scores on the COMLEX-USA Level 2-PE: An Analysis of the Skills Assessed
  14. SPECIAL COMMUNICATION
  15. Cullen Sign and Grey Turner Sign Revisited
  16. CASE REPORT
  17. Disseminated Varicella-Zoster Virus After Vaccination in an Immunocompetent Patient
  18. CLINICAL IMAGES
  19. Gout Flare With a Draining Tophus
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