Letter to the Editor
Open Access
Chronic tophaceous gout: Unique presentation in a
Bulgarian patient!
Ivanka Temelkova1, Jose Carlos Cardoso2, Georgi Tchernev1*
1Onkoderma- Clinic for Dermatology, Venereology and Dermatologic Surgery
2University Hospital of Coimbra, Portugal
2University Hospital of Coimbra, Portugal
*Corresponding author: Prof Dr. Georgi Tchernev, Onkoderma- Clinic for Dermatology, Venereology and Dermatologic Surgery General Skobelev
26, 1606 Sofia, GSM: 00359885588424
E-mail:@
E-mail:
Received: September 27, 2019; Accepted: September 27, 2019; Published: September 30, 2019
Citation: Temelkova I, Cardoso JC, Tchernev G (2019) Chronic tophaceous gout: Unique presentation in a Bulgarian patient!. Clin Res Dermatol Open Access 6(4): 1-2. DOI: 10.15226/2378-1726/6/4/001100
We present a 47 year old man, complaining about the
appearance of solid oval formations in the area of the elbows and
right hand with about one year duration (fig. 1a-d). The patient
has a metabolic syndrome. According to the anamnestic data, the
patient had suffered from gouty tophi in the past and has been
treated for gout, but at the time of the examination in the clinic
he was completely asymptomatic. Radiography and histologic
examination has been performed in an orthopedic ward
with a conclusion for gouty tophi. During the dermatological
examination, solid, nodular lesions were found in the area of the
two elbow joints (fig. 1a-b). A formation of the same character
was also visualised at the base of the thumb on the right hand
(fig. 1c-d). Paraclinical data were indicative for the presence of
dyslipidemia. Тhere was no evidence of an acute gout attack.
Based on clinical, anamnestic and laboratory findings, it was
concluded that it is a patient with tophaceous gout affecting
the elbow joints and the base of the right thumb. There were no
available data for renal complications. Performance of surgical
correction has been planned in an orthopedic department.
Figure. 1a-1d: Chronic tophaceous gout, with subcutaneous tophi in the area of the two elbow joints and the base of the thumb on the right hand.
In the prevailing number of cases, chronic tophaceous
gout frequently occurs after 10 years or more of recurrent
polyarticular gout [1]. According to the literature, tophi are
rarely observed in patients without a prior history of gouty
arthritis [2]. However, the possibility for occurrence of tophi
as an initial manifestation of the gout has been described [1,
2]. More interestingly, the available data indicate that large
tophi are unusual in chronic gout [1]. The most common areas
for gouty tophi localization include helix of the ears, on fingers,
toes, wrists and knees, on the olecranon bursae, Achilles tendons
[1]. However, there are atypical forms of presentation such as
finger pad tophi in the context of chronic Raynaud phenomenon
[3]. In these cases, the differential diagnosis of white papules
or nodules on the finger pads includes gout, calcinosis cutis,
chondrocalcinosis (pseudogout), pyogenic pustules, and oxalosis
[3]. In rare cases, gouty tophi may resemble clinically to a viral
warts on the soles [4]. It is important to note that usually gout
tends to present as articular disease first, and cutaneous gout
forming tophi usually correlate with chronicity and uncontrolled
disease [4]. These facts determine the need on the one hand to
consider the possibility for a tophaceous gout in patients with
atypical papules or nodules on the soles and finger pads, and on
the other – in cases of established gout, the treatment should be
undertaken early in order to avoid the evolution of the disease
to the chronic tophaceous form responsible for joint deformities
and their functional consequences [1,4].
- Aradoini N, Talbi S, Berrada K, Abourazzak F, and Harzy T. Chronic tophaceous gout with unusual large tophi: case report. doi:10.11604/pamj.2015.22.132.6447
- Shmerling R, Stern S, Gravallese E and Kantrowitz F. Tophaceous deposition in the finger pads without gouty arthritis. Arch Intern Med. 1988;148(8):1830-2.
- Zarbafian M and Dutz J. Finger pad tophi in a patient with Raynaud phenomenon. JAAD Case Rep. doi: 10.1016/j.jdcr.2016.10.013
- Bossart S, Sidler D, Blum R and Hunger R. Gout tophi on the soles resembling viral warts. Clin Case Rep. 2018 doi: 10.1002/ccr3.1539