Chronic Tophaceous Gout
A structured MRCP (UK) PACES approach to assessing chronic gout, recognising tophi, identifying secondary causes, counselling patients and planning long-term urate-lowering therapy.
Case Scenario
You are the medical registrar in the outpatient clinic.
An 84-year-old gentleman has experienced recurrent attacks of pain affecting his fingers and has gradually developed multiple painless swellings around his hands.
Take a focused history, perform an appropriate examination, explain your diagnosis and discuss the management plan.
PACES Approach
1. Focused History
- Characterise the joint pain.
- Identify previous acute attacks.
- Look for secondary causes.
- Assess functional limitation.
- Screen for complications.
2. Focused Examination
- Inspect affected joints.
- Look for gouty tophi.
- Assess deformity.
- Check range of movement.
- Look for systemic clues.
3. Explain Diagnosis
- Crystal deposition disease.
- Chronic uncontrolled hyperuricaemia.
- Tophus formation.
- Need confirmation.
- Long-term treatment available.
Focused History Framework
Opening Question
"You've been having repeated pain and swelling in your fingers. Could you tell me more about it?"
Pain Assessment (SONE)
- Site – Which joints are affected? Any feet, ankles or knees?
- Onset – Sudden attacks or gradual progression?
- Nature – Severe pain? Redness? Swelling? Warmth?
- Exacerbating factors – Movement? Night-time attacks? Alcohol? Rich meals?
- Relieving factors – Rest? NSAIDs? Colchicine?
- Functional impact – Difficulty writing, gripping or dressing?
History Suggestive of Gout
- Previous attacks involving the first MTP joint.
- Episodes resolving completely between attacks.
- Night-time onset.
- Increasing frequency over time.
- Development of hard nodules around joints.
- Previous diagnosis of hyperuricaemia.
Risk Factors & Secondary Causes
- Hypertension.
- Chronic kidney disease.
- Diuretic therapy.
- Alcohol excess.
- Obesity.
- Psoriasis.
- High-purine diet.
- Recent chemotherapy.
- Family history of gout.
Focused Examination
Inspection
- Asymmetrical small joint swelling.
- Gouty tophi over fingers.
- Joint deformity.
- Overlying erythema during active inflammation.
- Ulceration or chalky discharge from tophi.
- Reduced hand function.
Look Specifically For
- Ear pinna (helix) tophi.
- Olecranon bursitis.
- Achilles tendon tophi.
- Forearm nodules.
- Foot deformity.
- Pressure-point tophi.
General Examination
- Blood pressure.
- Features of CKD.
- Obesity.
- Psoriatic skin lesions.
- Signs of metabolic syndrome.
- Evidence of infection.
Likely Positive Findings
- Firm, irregular subcutaneous tophi affecting fingers.
- Asymmetrical involvement of the small joints.
- Chronic joint deformity.
- Reduced grip strength.
- Olecranon bursitis.
- Tophi involving the helix of the ear.
- Possible overlying skin ulceration with chalky white material.
Differential Diagnosis
| Condition | Helpful Clinical Clues |
|---|---|
| Chronic tophaceous gout | Tophi, previous acute attacks, asymmetrical joints |
| Rheumatoid arthritis | Symmetrical MCP/PIP disease, prolonged morning stiffness |
| Psoriatic arthritis | Psoriasis, nail pitting, dactylitis |
| Osteoarthritis | Mechanical pain, Heberden's and Bouchard's nodes |
| Pseudogout | CPPD disease, commonly affects knees and wrists |
| Septic arthritis | Fever, severe pain, acutely inflamed joint |
Investigations
Baseline Blood Tests
- Full blood count.
- CRP and ESR.
- Renal profile.
- Liver function tests.
- Serum urate.
- HbA1c.
- Lipid profile.
Joint Aspiration (Gold Standard)
- Needle-shaped monosodium urate crystals.
- Negative birefringence on polarised microscopy.
- Gram stain.
- Culture to exclude septic arthritis.
Imaging
- X-ray hands and feet.
- Punched-out erosions.
- Overhanging edges ("mouse-bite" erosions).
- Joint space preserved until late disease.
- No peri-articular osteopenia.
- Ultrasound may demonstrate the double contour sign.
Explaining the Diagnosis to the Patient
"From your history and examination, I think you most likely have chronic tophaceous gout. This occurs when uric acid builds up in the body over many years and forms crystals inside joints and beneath the skin. These crystal deposits form the hard lumps called tophi, which can damage joints if left untreated."
"The good news is that gout is one of the few forms of arthritis that can usually be controlled very effectively with long-term treatment. We will confirm the diagnosis with blood tests and, if appropriate, by analysing fluid from an affected joint."
Management
Acute Attack
- NSAIDs (if appropriate).
- Low-dose colchicine.
- Oral or intra-articular corticosteroids if NSAIDs/colchicine are unsuitable.
- Rest and elevate the affected joint.
- Adequate hydration.
Long-term Management
- Urate-lowering therapy for recurrent attacks or tophaceous gout.
- Treat-to-target serum urate strategy.
- Review adherence regularly.
- Manage cardiovascular risk factors.
- Monitor renal function.
Lifestyle Advice
- Weight reduction if overweight.
- Reduce alcohol intake, particularly beer and spirits.
- Reduce intake of purine-rich foods.
- Encourage good hydration.
- Regular exercise.
Examiner's Corner
Why does gout occur?
Gout results from deposition of monosodium urate crystals caused by persistent hyperuricaemia. Crystal deposition triggers intense neutrophilic inflammation during acute attacks and eventually leads to chronic joint destruction and tophus formation.
Who should receive urate-lowering therapy?
- Tophaceous gout.
- Two or more attacks per year.
- Chronic kidney disease.
- Radiographic joint damage.
- Urate nephrolithiasis.
- Very high serum urate levels.
Why should urate-lowering therapy not usually be started during an acute flare?
Starting urate-lowering therapy during an untreated acute attack may prolong or worsen symptoms. In most patients it is commenced after the acute inflammation has settled, with prophylactic colchicine or NSAID cover according to current guidance.
How do gout and pseudogout differ?
| Feature | Gout | Pseudogout |
|---|---|---|
| Crystal | Monosodium urate | Calcium pyrophosphate |
| Microscopy | Needle-shaped, negatively birefringent | Rhomboid, weakly positively birefringent |
| Common joint | 1st MTP | Knee |
| X-ray | Erosions | Chondrocalcinosis |
Common PACES Viva Questions
- What are the risk factors for gout?
- What medications increase uric acid levels?
- How is gout confirmed?
- How would you manage an acute attack?
- What are the indications for long-term urate-lowering therapy?
- What serum urate target would you aim for?
- How do you counsel a patient regarding diet and alcohol?
Pathfinder Pearls
Common Pitfalls
- Diagnosing gout solely on the basis of serum urate levels.
- Failing to aspirate an acutely inflamed joint when septic arthritis is possible.
- Ignoring secondary causes such as chronic kidney disease or diuretic therapy.
- Providing medication without lifestyle counselling.
- Stopping urate-lowering therapy once symptoms improve.
- Not monitoring serum urate after treatment is started.
- Missing tophi in the ear, elbows or Achilles tendon.
Key Take-home Messages
- Tophaceous gout is a marker of longstanding uncontrolled hyperuricaemia.
- Joint aspiration with crystal analysis remains the diagnostic gold standard.
- Always look for secondary causes including CKD and medications.
- Long-term urate-lowering therapy prevents joint destruction and tophus progression.
- Successful management combines medication, lifestyle modification and regular follow-up.
Master MRCP (UK) PACES Long Clinical Consultations
Join PACES Pathfinders to develop a structured approach to rheumatology stations through examiner-led teaching, realistic mock consultations, personalised feedback and an extensive online Learning Library.