An elderly man presenting polyarthritis diagnosed as chronic tophaceous gout

Abstract

An 85-year-old man was admitted to our hospital for swollen and painful bilateral lower legs and a high fever. He was initially diagnosed with acute cellulitis and treated with antibiotics. Several days after the improvement of his swollen legs, he complained of both shoulder and arm pain. The laboratory data at this time were as follow: C-reactive protein 10.7 mg/dL, uric acid 8.7 mg/dL, and creatinine 1.07 mg/dL. Both rheumatoid factor and anti-CCP antibody were negative. Whole-body gallium scintigraphy showed a high pathological accumulation in both the shoulders and left wrist. As polymyalgia rheumatica was suspected, oral prednisolone (PSL) of 10 mg/day was started. The patient's shoulder pain improved and he was discharged. However, he was hospitalized twice in the next month because of left shoulder, left knee, right arm, and right wrist pain. During the third hospitalization, we found a subcutaneous nodule on right toe. Aspiration material from the nodule was a white paste, showing acicular crystals under the microscope. According to these findings, the nodule was diagnosed as a tophaceous nodule, and recurrent episodes of polyarthritis were diagnosed as chronic tophaceous gout. Low-dose PSL was continued and febuxostat was added. This patient had multiple risk factors for chronic tophaceous gout: obesity, a habit of drinking, diabetes mellitus, hyperlipidemia, congestive heart failure, and interruption of allopurinol treatment. We herein discuss the clinical course of the patient, the interruption of allopurinol treatment and polypharmacy in elderly patients.