Ulcerated tophaceous gout

A 51-year-old male presented with ulcerated nodules over the bilateral elbows. These nodules had been present for >10 years; however, 3 weeks prior to presentation, they became more painful and chalky material started to drain from them. At that time, the patient was prescribed a short course of prednisone, which led to mild subjective improvement in swelling and pain. On presentation, physical examination of the right elbow revealed a tender, deep-red, exophytic nodule with central ulceration surrounding deposits of solid, yellow-white chalky material (Figure 1). On the left elbow, there was a similar tender, deep-red firm plaque that distally extended to the forearm with central ulceration and chalky debris. The patient exhibited limited extension and flexion of the left elbow. Additionally, there were several yellow-orange nodules overlying the small joints of the bilateral hands and wrists. An X-ray of the elbows revealed significant swelling with foci of mineralization. An arthrocentesis and culture of the left elbow identified uric acid crystals without bacteria. In this patient with a history of tophaceous gout, the clinical presentation was most consistent with ulcerated tophaceous gout. The patient was instructed to continue the dose of allopurinol and surgical excision and debridement of the gouty tophi on the left elbow was performed.

Figure 1.

Ulcerated tophaceous gout involving the right elbow joint.

An elbow with a deep-red, exophytic nodule with central ulceration surrounding a deposition of solid, yellow-white chalky material is shown.

Tophaceous gout is a rare condition characterized by the subcutaneous accumulation of monosodium urate crystals in a matrix of lipids, proteins, and mucopolysaccharides, surrounded by giant cell inflammation (1, 2). Ulceration is rare and occurs when tophi break through the skin. The most commonly reported sites of ulcerations are over the first metatarsophalangeal joints as well as on the joints of fingers, wrists, elbows, and ankles. Comorbidities that impair wound healing, such as diabetes mellitus, peripheral vascular disease, and hypertension, are commonly noted in patients with ulcerated tophaceous gout (1). A Significant morbidity is associated with this condition considering the extent of pain, impaired mobility, and risk of secondary infection (3).

Although tophaceous gout is often clinically diagnosed, when ulceration occurs, arthrocentesis of synovial fluid is necessary to rule out a secondary septic arthritis. Histopathology of a gouty tophus demonstrates palisaded granulomas surrounding amorphous, gray-blue material with a feathery appearance. Because the ulceration of a tophus is rare, there are no standard guidelines for its treatment. In case reports and small case series, several medical and surgical treatment modalities have been demonstrated to expedite the resolution of pre-existing ulcers as well as prevent superimposed infections of pre-existing ulcers and future ulcer formation (1). Medical management includes long-term antihyperuricemic agents (i.e., allopurinol and probenecid) and topical wound care aimed at preventing secondary infection and promoting healing (i.e., mupirocin, 3% citric acid in petroleum jelly, allogeneic culture dermal substitute, silver-containing dressing, and heterologous lyophilized collagen) (1). Surgical management should be considered for patients with infection of tophi, mechanical impairments, uncontrollable pain, and cosmetic disfigurement (3). Intralesional shaving, hydrosurgery, and skin grafting are the most commonly performed surgical interventions (4). Curettage and debridement are used less frequently due to high rates of delayed wound healing and skin necrosis (5).