A 43 yr old non-diabetic and non-hypertensive male† presented to the department of Rheumatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India, in January 2019, with multiple nodules in both hands and bilateral heel pain for five years. No similar history in the family was observed. Examination revealed firm, non-tender nodules on the dorsum of both hands (Fig. 1) and tenderness with minimal swelling of bilateral Achilles tendon. Systemic examination was normal. His complete blood counts, kidney function tests, liver function tests, erythrocyte sedimentation rate, C-reactive protein, and serum uric acid were normal. He had elevated serum total cholesterol (900 mg/dl), low-density lipoprotein (571 mg/dl), triglycerides (217 mg/dl), high-density lipoprotein (126 mg/dl) with very low-density lipoprotein being normal. Evaluation for coronary artery disease was negative. Eye examination revealed corneal arcus (Fig. 2). A diagnosis of tuberous xanthoma was made. Tophaceous gout is a common differential for this condition where monosodium urate crystals are deposited over ligaments and tendons with repeated painful attacks in the background of hyperuricemia. He received atorvastatin and ezetimibe along with analgesics and physiotherapy. Follow up after three months revealed reductions in lipid levels and improvement of heel pain.
Fig. 1.
Multiple, firm, non-tender nodules of various sizes on the dorsum of both hands.
Fig. 2.
Corneal arcus (white arrows) along with cholesterol xanthomas (black arrows) in both eyes.
Footnotes
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Conflicts of Interest: None.