Many of my photographs of gouty tophi show isolated joints. Many case reports refer to painless tophi. Though quite alarming, individual photographs of tophi sites do not seem unduly worrying. Here we see what happens as small isolated painless tophi grow into widespread tophi with high risk of infection.
This report about widespread painless tophi is my layman’s summary of a case report of a 30 year old male.
Widespread Painless Tophi Report
This is a summary of:
- Painless nodules over joints with ulceration
- Apurva Khare, Rakesh Biswas
- BMJ Case Reports 2011
Widespread Painless Tophi Report Description
The gout patient had swellings over left elbow, left ankle, and base of the big toe joint of both feet. He had ulcers over swelling of right big toe joint and top of same foot for 3 months. The ulcers were discharging chalky fluid that revealed uric acid crystals when examined under polarizing microscope. He also had 6 months of excess pale urine and slight fever.
There was family history of kidney disease. The patient never had a gout attack and was started on allopurinol, with paracetamol (acetaminophen) stopping the fever. Abnormal kidney function tests after 2 weeks on 300 mg allopurinol caused uric acid lowering treatment to switch to Uloric (febuxostat).
The case study reports that uric acid reduced from 10.5 to 7.5 mg/dL, but does not state what, if anything, was done to lower uric acid to a safe level.
The authors note that tophi are unusual without previous gout attacks, and they refer to previous studies. [1-2] They note that previous studies always involved fingers, which are not affected in this case. They also note that kidney problems were common in previous cases. The mild kidney problems found with this patient led to the switch from allopurinol to Uloric. 
They conclude with:
This case has been primarily submitted for the striking image of the gouty tophi.
Widespread Painless Tophi Report Photographs
So, if you are ready for some striking examples of gouty tophi, here they are:
Widespread Painless Tophi: Next Steps
Though interesting, this case study about widespread painless tophi doesn’t explain how things got so bad.
I can only assume that the gradual process of slow tophi growth never seemed serious enough until infection set in. When a small lump appears, especially if it is painless, there is a tendency to “wait and see.” We have no details here, but from my own experience, I imagine that this patient had a small lump that was not trouble, so he waited. Then it grew, and perhaps he was too embarrassed to seek attention. Maybe if it had hurt earlier, he would have sought treatment sooner.
I have written before about the curse of painless gout. The advantage is no pain (which most gout sufferers prize above all else). The disadvantage is slow growing danger.
In this case, the danger presented as an infected foot. We do not know what happened next, but I presume the foot was saved. Here, tophi damaged our biggest organ, the skin, but all organs are at risk. Death from kidney disease is not uncommon, and heart failure has been attributed to tophi affecting the cardiovascular system.
Next steps should be obvious – if you have unusual lumps or swellings, see a doctor immediately. If you have gout, reduce uric acid to 5mg/dL (0.30 mmol/L) before the tophi grow.
Leave Widespread Painless Tophi to browse more Tophi Guidelines
Widespread Painless Tophi References
- Yu TF. Secondary gout associated with myeloproliferative diseases. Arthritis Rheum 1965;:765–71.
- Wernick R, Winkler C, Campbell S. Tophi as the initial manifestation of gout: report of six cases and review of the literature. Arch Intern Med 1992;:873–6.
- Reinders MK, Jansen TL. Management of hyperuricemia in gout: focus on febuxostat. Clin Interv Aging 2010;:7–18. Uloric (Febuxostat) Versus Allopurinol
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