Gout
The Broad Spectrum of Urate Crystal Deposition: Unusual Presentations of Gouty Tophi

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Objectives

Gout is typically described as an inflammatory arthropathy that affects the peripheral joints. Our aim was to describe atypical and rare clinical presentations of gouty tophi to help increase physician awareness and aid in patient care.

Methods

The relevant English literature of unusual gout manifestations was searched using the keywords gout, toph*, monosodium urate, uric acid, unusual, and rare. Well-described case reports, case series, and review articles were evaluated and included, if relevant, in the literature review.

Results

Review of the literature revealed many unusual manifestations of gouty tophi involving the head and neck, skin, viscera, bones, tendons, ligaments, nerves, and axial skeleton. Transplant recipients, women, and elderly people are particularly susceptible to developing tophi. Furthermore, gout can cause diagnostic dilemmas, as it can be a great mimicker of and can coexist with infection, malignancy, and other connective tissue diseases. Imaging modalities can help detect tophi in atypical locations.

Conclusions

Tophi can present in unexpected locations, even as the first sign of gout, and vigilance is required when unusual symptoms or signs occur in a patient with gout.

Section snippets

Materials and Methods

We performed a literature search in the PubMed and EMBASE databases to identify unusual manifestations of gout. The search was limited to publications in English and from 1965 through 2011. The database search was conducted using the following terms: toph* AND gout OR toph* AND monosodium urate; OR toph* AND uric acid. The computerized search was completed with a manual search of pertinent reference lists from the relevant articles retrieved. The 2 databases (PubMed and EMBASE) were then

Typical Localization

Tophi generally form in or close to joints, in the subarticular regions of bone, in bursae, tendon sheaths, and articular cartilage. Aspirations of articular joints often demonstrate, on gross inspection, collections of white chalky substances floating in synovial fluid that are consistent with tophi. Tophi can erode underlying bone and produce typical “punched out” lytic lesions with overhanging edges of bone, which is one of the radiologic hallmarks of gouty arthropathy. Crystal deposition is

Transplant

Hyperuricemia and gout are prevalent in organ transplant recipients, and these patients have an accelerated clinical course when compared with the classic progression of gout (90). In addition to common risk factors for gout, calcineurin inhibitors (cyclosporine and to a lesser degree tacrolimus), which are used as anti-rejection medications, pose an additional risk in this population. The mechanism by which these medications results in hyperuricemia is complex and poorly understood, but

Gout as a Great Mimicker

Gout can deposit in unusual sites and mimic tumors with reports including deposits in the skin and muscles simulating soft tissue tumors, hyperkeratotic periungual lesions, and laryngeal deposits appearing as squamous cell carcinoma, tophi imitating intra-articular synovial tumors of the knee, intraosseous gout seeming to be bone tumors, spinal gout looking like metastatic disease, and internal organ involvement appearing to be malignancies of the pancreas and colon (15, 50, 51, 101, 102, 103,

Diagnostic Imaging for Early Detection

Conventional radiography has traditionally been used to detect calcified tophi and erosions with sharp margins and overhanging edges that are characteristic of gout. Erosions, however, are not always clear on plain radiography and tophi are not always calcified. Other imaging modalities, such as CT, magnetic resonance imaging (MRI), and ultrasound (US), can assist in the diagnosis of gout if conventional radiography is inconclusive or unrevealing, as they detect tophi and erosions at greater

Acknowledgments

The authors would like to thank Dr Michael Klein, director of Laboratory Medicine, Hospital for Special Surgery, and Dr Hollis Potter, director of magnetic resonance imaging, Hospital for Special Surgery, for their assistance in selecting appropriate images for this article.

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    Theodore Fields, MD, serves on the Advisory Board and Speakers' Bureau for Takeda, Savient, and URL Pharmaceuticals.

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