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Rheumatology 2006 45(9):1095; doi:10.1093/rheumatology/kei141
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

An unusual presentation of polyarticular tophaceous gout

D. Khanna and A. Shrivastava

Department of Clinical Immunology and Rheumatology, KLES Hospital and Medical Research Centre, Belgaum, Karnataka, India

Correspondence to: A. Shrivastava, Department of Clinical Immunology and Rheumatology, KLES Hospital and Medical Research Centre, Belgaum, Karnataka, India. E-mail: arun453{at}yahoo.com


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A 60-yr-old man presented with a 15-yr history of episodic, inflammatory polyarthritis with subcutaneous tophi over the left elbow. He was diagnosed with polyarticular gout after gouty crystals were demonstrated from joint fluid. He was treated with colchicine and allopurinol. He was seen after 1 month when he complained of the spontaneous development of multiple intradermal bullae over the lateral and medial aspects of the feet, heels and in the skin overlying the tendoachillis (Fig. 1; see also supplementary Figs 2 and 3 available at Rheumatology Online). The deposits were mildly painful and yellowish white without signs of inflammation. Aspiration from the deposits revealed chalky fluid containing needle-shaped crystals. The patient was diagnosed as tophaceous gout with bullous tophi.


Figure 1
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  		FIG. 1. Feet showing bullous tophi.

 
Tophi are usually firm nodular subcutaneous deposits, but may rarely be intradermal pustules or plaques. Tophi presenting as superficial bullae have only once been reported in the English literature [1]. That case was precipitated by a burn causing local tissue injury in one patient. In our patient, the tophi presented as intradermal bullae only on the margins of the sole and heel. Since acute or repetitive trauma is a known precipitating factor of gouty attacks, it could be postulated that imperceptible trauma to the feet precipitated the tophaceous bullae. The skin deposits did not invite the inflammatory response, possibly because the patient was on colchicine.

The authors have declared no conflicts of interest.


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Supplementary figures are available at Rheumatology Online.


   References
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  1. Schumacher HR. (1977) Bullous tophi in gout. Ann Rheum Dis 36:91–3.[Abstract/Free Full Text]

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This Article
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