Nonarticular gout: hyperuricemia and tophus formation without gouty arthritis

Abstract

The sequence of events from asymptomatic hyperuricemia to acute gout, intercritical gout, and finally chronic tophaceous gout is well established. One-fifth of patients who suffer acute gout eventually develop tophaceous deposits if not treated with hypouricemic drugs (1). The patients described here paradoxically developed tophi without any history of acute gouty arthritis. One patient had coexistent rheumatoid arthritis and the other four showed various degrees of renal impairment, a situation inviting speculation on the mechanism of inhibitory factors involved in acute gout. lone approximately 7 mg daily, and in 1978 penicillamine was started. After taking penicillamine 6 months he developed proteinuria, and a chalky deposit was noted on the pinna of one ear (Figure 1). Salient investigations included a normal pyelogram and urine microscopy, creatinine clearance of 126 ml/minute, and proteinuria of 2.1 gm/24 hours.Renal biopsy showed no abnormality by light microscopy in the cortex. Immunofluorescent staining showed diffuse and discrete granular deposits of IgG around the periphery of the glomerular capillary loops. By electron microscopy, numerous small electrondense deposits were identified on the epithelial cell aspect of the glomerular basement membrane. There was fusion of the foot processes of the epithelial cells but the mesangial regions were within normal limits. These changes are compatible with penicillamine-induced glomerulonephritis. In addition, a typical gouty tophus was identified in the medulla (Figure 2). Dissolution of urate from the tissues had been minimized since urate is relatively insoluble in the alcoholic acidic fixative used (Duboscq-Brazil). Polarized light microscopy showed the presence of crystals that stained positively by the Gomori methenamine technique, identifying them as salts of either calcium or urate (2). However preincubation of the sections in a saturated solution of lithium carbonate dissolved out the crystals, specifically identifying them as urate which, unlike calcium salts. is soluble in such a solution. A positive urate control specimen and a duplicate specimen preincubated in lithium carbonate confirmed these findings.Polarized light microscopy of the deposit in the ear showed variable sized needle-shaped crystals that gave a negative sign of birefringence typical of mono-

Fingertip Tophi without Gouty Arthritis

“…Case 1 in the scries of Hollingworth et al [8] is some what different because he was younger, had no tophi in the fingertips or fingerpads and showed normal renal function; this patient might have had common gout without a history of acute gouty arthritis. Moreover, he also had rheumatoid arthritis, which might masquerade clinical manifestations.…”

“…Case 3 [8], in addition to fingertip tophi, also showed tophi in other common locations such as the olecranon bursa, but he fulfilled the other criteria of this special subgroup of gouty patients. Martin [10] reported 2 patients with tophi in the fingerpads who lacked a history of acute gouty arthritis but showed neither evidence of renal failure nor intake of diuretic drugs.…”

“…Patients with chronic renal failure have a decreased uric acid glomerular filtration; nevertheless, they seldom suffer from gout [7]. The initial presentation of gout with tophi and without any history of acute gouty arthritis is a rare event, and there are only a few reports in the literature [8][9][10]. Table 1 sum marizes the main clinical features of the cases collected from the literature.…”

L’atteinte des tendons fléchisseurs dans la maladie goutteuse. À propos d’un cas et revue de la littérature

“…Les dépôts tophacés se retrouvent plus fréquemment au niveau de l'hélix de l'oreille et des orteils [1].…”

Gota tofácea: ¿indisciplina o desconocimiento?

“…Por último, la artritis gotosa crónica o gota tofá-cea, se caracteriza por la presencia de tofos que, en ocasiones, son el origen de erosiones del cartílago y del hueso subcondral 5 . Se trata de tumoraciones de tamaño variable y corresponden a depósitos de UMS rodeados de células mononucleares con reacción a cuerpo extraño.…”