Best Tophi Picture

I think this is the best tophi picture. Because it shows successful tophi treatment. Most tophi photographs are horrible. But I think you should know the dangers of untreated gout.

Despite the advances in science that mean we can now control gout, there is a tiny minority who cannot tolerate common uric acid-lowering treatment. If you do not get uric acid to safe concentration, you are doomed to the continuous growth of tophi. So, you might treat the pain, but can you control the gout?

Pain relief without uric acid control means more and more uric acid crystals that will eventually show themselves as gouty tophi.

Continue reading about the best tophi picture

Thumb Tophi – Worst Symptom of Thumb Gout

Thumb tophi join the collection of lumps on the hand for victims of tophaceous gout.

As you can see from the photograph below, a thumb tophus can be particularly debilitating if it stops you gripping effectively.

The one shown below is not the worst I’ve seen, but bad enough to make you think twice about leaving your uric acid level above 5mg/dL.

Unfortunately, we do not have a corresponding photograph of the thumb after treatment, but almost all similar case studies show that the tophi dissolve if uric acid is maintained at a suitably low level. If you use the search boxes near the top and bottom of each page to search for lower faster, you will see that aiming for low uric acid is always a good idea when tophi are present.

Thumb Tophi Photograph

Thumb Tophi with Gout Crystals

Thumb Tophi Information

The photograph is one of a series of seven gout pictures from “A Photo Essay of Gouty Arthritis” in Consultant Live[1]. As this is not a regular gout case study, we do not have all the background. I have paraphrased the description of the photograph below, and you can see the original text if you click the photograph.

The thumb of a 70-year-old man shows a white patch surrounded by red inflammation.

The thumb was lanced, and fluid collected, which was analyzed under a microscope, revealing crystals. The crystals split polarizing light in a way that identified them as uric acid crystals. This confirmed a diagnosis of gout.

Results of tests showed a uric acid level of 8.5 mg/dL (0.51 mmol/L) in the blood. The original description refers to a normal range, which is meaningless. You will find information about why this is meaningless if you search for normal uric acid in the search box above or below.

Gout appears first in a single joint, for most gout patients. The essay mentions 70%, but there is no reference for this. Gout involving multiple joints is seen occasionally. This case, where gout is diagnosed despite no swollen joints, is rare.

Thumb Tophi: Next Steps

In this example, the patch of gout crystals is very clear, presumably due to skin bursting at some point. Often, the tophi show as lumps of varying size. If you have unusual growths on your thumbs, you should consult your doctor immediately. You do not have to become a Gout Victim. Also, see more facts for Gout Victims.

Leave Thumb Tophi to browse other Tophi pages.


Thumb Tophi References

  1. Original from Consultant Live article/10162/2103463. Now renamed Patient Care Online. Flagged for review to present PDF file.


Thumb Tophi Document Change History

Thumb Tophi Document Change HistoryTo read the document change history, click the GoutPal History image on the right.

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Uric Acid Back Pain: The Heavy Load Of Gout

Uric Acid Back Pain ImageA new report on uric acid and back pain reminds me of the critical consequences of failure to manage gout properly.

Are you the type of person who wants to avoid daily uric acid treatment because you can stand the agony of a swollen big toe?

You might think again when your back is crippled and you can no longer stand upright.

I’m not one for scaremongering, but I do get frustrated by people who suffer years of gouty agony because they refuse to control uric acid. OK, so painkillers can mask the pain, but they cannot stop the inevitable invasive growth of uric acid deposits.

The big toe is the most common joint to get affected, but if left untreated, high uric acid levels will lead to urate deposits in every joint. This is more than a painful nuisance – these uric acid deposits known as tophi eat into bone, cartilage, and tendons causing permanent joint damage.

Most of us are lucky enough to live in a society where joint reconstruction surgery is a possibility, but why put yourself at that risk?

And I did mention every joint. Foot gout is a common problem because there are lots of joints in the foot. There are also lots of joints in the spine, and gout in the back, though fairly uncommon, is serious enough for you to be very afraid.

In gout management, there is too much emphasis on short term pain relief, and insufficient awareness of the consequences of allowing gout to reach the tophaceous stage. A single tophus (the name given to uric acid crystals when they form a lump in the body) often means severe joint movement restriction. This is quite common on the hands, where groups of tophi (the plural of tophus) tend to restrict finger movement. When this happens in the spine, back movement restriction becomes critical, and total incapacity from spine distortion is a real risk.

Samuels and colleagues reported a particularly bad case of spinal gout in the June issue of Bulletin of the NYU Hospital for Joint Diseases[1]. The image above shows how tophi in and around the spine have severely distorted the patient’s back. The report reveals that this impaired the ability to stand long enough to take a shower.

Fortunately, the patient responded well to allopurinol, even though he required a dose of:

750 mg daily to achieve a target serum uric acid level less than 6.0 mg/dL.

As I mentioned, uric acid back pain in the form of tophaceous spinal gout is uncommon, but the Samuels report does manage to cite 7 other cases, and there will be many more that go unreported.

Uric Acid Back Pain: Other Causes

As well as tophi, uric acid can cause back pain in other ways.

I have experienced it from bad posture caused by limping. Whenever I had gout in my feet or knees, I often walked awkwardly to try and limit the pain. This is a common cause of back pain. It isn’t exactly gout in the back, but the cause is the same. Excess uric acid should be treated long before gout affects your back.

Another common cause of back pain is kidney stones. This is especially common with lower back pain. Again, early treatment is essential. Uric acid kidney stones can cause permanent damage and chronic kidney disease.

Uric Acid Back Pain: Next Steps

If you think your back pain might be uric acid related, what should you do next?

It really is not worth letting gout go untreated this long. Are you showing any symptoms of tophaceous gout, or indeed gout symptoms of any kind, such as swollen joints? If so, you need to get your uric acid level checked by your doctor, and controlled today.

If you are not sure what to say to your doctor, ask in the gout forum. You can also use the forum if you do not understand what your doctor tells you about uric acid back pain. Following comment(s) below, this page is now under review. If you have ideas for improving this page, please add a reply to Improving Uric Acid Back Pain Page.


Uric Acid Back Pain References

  1. Authors: Jonathan Samuels, M.D., Robert T. Keenan, M.D., M.P.H., Rena Yu, M.D., Michael H. Pillinger, M.D., and Tibor Bescke, M.D. Title: Erosive Spinal Tophus in a Patient with Gout and Back Pain. Published: June 2010.

Uric Acid Back Pain: Document History

Date Revision
Jul 22, 2010 (first archive). First Published.
May 05, 2015 (archive). Added notes about other causes of gout-related back pain. Also, added links to gout forum.
Oct 10, 2016 (archive). Flagged for review after comment from Joanne. If you have ideas about improving this page, please add your replies to Improving Uric Acid Back Pain Page.

If you see other gout pages that I should improve, please suggest a GoutPal page review.

Gouty Tophi & Bone Erosion

Gouty tophi are usually noticed under the skin, and are not usually painful until they burst through the skin, or become infected.

We tend to ignore them in the early stages, and concentrate more on relieving the pain from acute gout flares.

But is this wise?

Now that technology allows us to see tophi growing into cartilage, tendons, and bones, we can see it is not wise. I’ve added some more important 2014 information to this 2010 article about early detection of joint damage from new gout scanning technology. First let us see how this technology shows early tophi leading to bone erosion and severe, painful, joint damage.

Continue reading Gouty Tophi & Bone Erosion

Doctor, do I have gout?

It’s been my sad duty today to tell someone that they have got gout.

First his doctor suspected gout but wasn’t sure. He ran the usual blood test for uric acid. The doctor didn’t understand the results, and suggested it was unlikely to be gout.

Like 3 in 4 doctors, he got confused between facts about laboratory reference ranges for uric acid, and facts about medical uric acid safety.

Our patient is left worrying what is wrong with him, and wondering what to do next. Someone had to step up and help this poor guy. That someone turned out to be me.

This is an ongoing story, fresh from the gout forum. As I write, I do not know how the story will end. Will our gout sufferer get the right diagnosis? Will he get the right treatment? Can he ever get the right lifestyle improvement advice if his gout is undiagnosed? You can find out by joining the gout forum link below.

Here are the simple gout facts we have learned so far.

Continue reading Doctor, do I have gout?

Finger Lost To Gout

This finger tophi review looks at a case study of advanced tophaceous gout causing loss of a finger through amputation.

Tophi are deposits of uric acid crystals that frequently occur under the skin, but can spread throughout the body. Unfortunately, tophi can grow and spread without the usual painful gouty arthritis most commonly associated with uric acid crystals. This often results in gout not being diagnosed properly.

Gouty Fingers Case Study

This is a layman’s review of:

Title:
Erosive polyarticular tophaceous gout: an unusually deforming and destructive presentation.
Authors:
Redmond CE, Babiker A, Redmond PL, O’Rourke KP.
Published:
BMJ Case Rep. 2013 Dec 10;2013.

Polyarticular means occurring in multiple joints.
Tophaceous gout is where gout has progressed to the stage where tophi are visible.

The case study contains a description, learning points, and references. It contains a photograph and an x-ray image. For clarity, I have omitted the gout x-ray from this review, though it does show some significant bone erosion, particularly around the joints. The authors claim this to be more extensive than previous cases.[1-3]

Gouty Fingers Case Description

An 87 year old male suffered from painful, swollen and deformed fingers. He had longstanding gout, which led to amputation of the middle finger of his left hand. The report mentions suboptimal treatment of gout, but offers no further explanation.

The patient’s right index finger was swollen with multiple tophi. There was severe loss of movement in the joints of the fingers. There was almost complete destruction of the middle and end finger joints in both hands.

Gouty Fingers PhotoBlood tests revealed normal uric acid levels. However, we know from other research, that “normal uric acid levels” are meaningless in the clinical context of gout management. Analysis of a sample from the right index finger confirmed the presence of uric acid crystals.

Treatment was longterm colchicine at 1mg per day, and 600mg allopurinol per day.

Gouty Fingers Case Learning Points

The report lists 3 learning points, though it is not clear who needs to learn from them, as all 3 are well-documented prior to the date of this report.

  • Advanced tophaceous gout can result from longterm untreated acute gout.
  • Severe gouty tophi in many joints can occur even with normal uric acid and inflammation blood tests. If in doubt, joint fluid should be examined for uric acid crystals.
  • Uric acid crystal deposits can lead to severe bone destruction, which may require amputation in rare cases.

Gouty Fingers: Next Steps

Though this case study does not reveal new information about gout, and how to manage it, it does emphasize the destructive nature of gout.

If you suspect gout, you really must take steps to get uric acid safe. Safe means 5mg/dL, or lower, and you need to take responsibility for it, as many medical practitioners are unaware of the dangers. Never settle for a normal uric acid test result. This gouty fingers case study confirms that if uric acid is not made safe, then bone destruction will happen.

Leave Finger Lost To Gout to browse other Finger Tophi pictures.


Gouty Fingers Case References

  1. Bloch C, Hermann G, Yu TF. A radiologic reevaluation of gout: a study of 2,000 patients. AJR Am J Roentgenol 1980;134:781–7.
  2. Samaras N, Rossi C. Images in clinical medicine. Tophaceous gout. N Engl J Med 2012;366:e6.
  3. Monu JUV, Pope TLJ. Gout: a clinical and radiologic review. Radiol Clin NA 2004;42:169–84.

Left Foot Tophi Study

These photographs of the left foot show tophi before and after treatment, as part of my Feet Tophi series.

This is a particularly bad case report of a 75 year old Caucasian man. As well as this large ulcerated tophi lump on his left foot, the patient had right foot tophi and left thumb tophi. It is not clear from the case study why gout was left untreated so long. The report speaks of the patient intentionally stopping allopurinol treatment 4 months earlier. However, tophi of this magnitude take far longer than 4 months to develop. It suggests that allopurinol treatment was below acceptable dosage. This is a common problem, and causes non-compliance as patients lose confidence in the medication.

Though my gout never got this bad, I had to argue the facts with doctors before getting sufficient allopurinol to achieve safe uric acid levels. Be warned! You might have to take control, and insist on appropriate uric acid lowering treatment to bring uric acid down to 5mg/dL or below.

In this gout study[1], the patient attended Emergency Department after a tophus on his left foot became painful for 5 days, then eventually burst. As well as the other tophi mentioned earlier, the patient had completely lost mobility of the first joint of his left foot.

X-rays revealed total destruction of the first joint, and amputation of the whole left foot was considered. Fortunately, surgeons attempted removal of damaged tissue, and thorough clean of the affected area first. After 6 weeks, all ulcers healed completely, and the patient remained symptom free six months later, except that mobility in the big toe never recovered.

Left Foot Tophi Images
Click for Left Foot Tophi Images details

In the discussion of the case, the authors note:

Tophi are typically found on the helix of the ears, on fingers, toes, wrists and knees, on the olecranon bursae [elbow], on the Achilles tendons and also rarely on the sclerae, subconjuctivally, and on the cardiac valves [eyes and heart]. They can cause pain and dysfunction and are rarely associated with ulcerations, bone fractures, tendon and ligament rupture, carpal tunnel and other nerve compression syndromes.

You can see other parts of the body that are affected by gouty tophi in the tophi guidelines.

Leave Left Foot Tophi to browse the Tophi guidelines


Left Foot Tophi References

  1. Multiarticular chronic tophaceous gout with severe and multiple ulcerations: a case report. Falidas E, Rallis E, Bournia VK, Mathioulakis S, Pavlakis E, Villias C.
    J Med Case Rep. 2011 Aug 19;5:397. doi: 10.1186/1752-1947-5-397.