Chronic Tophaceous Gout

History Taking

Chief Complaint:

• Persistent and recurrent episodes of intense joint pain and swelling.

History of Presenting Complaint:

• Frequency and duration of gout attacks.

• Presence of joint redness, heat, swelling, and tenderness during the episodes.

• Progressive stiffness and difficulty in movement due to the affected joints.

• Tophi (chalky, hard nodules) presence, commonly found in the outer edge of the ear, elbows, knees, fingers, and toes.

• Areas affected by the attacks, classically the big toe (podagra) but other joints may be involved.

• Onset, intensity, duration, and any relieving or exacerbating factors for pain.

System Review:

• Renal: Symptoms suggesting renal calculi, history of renal colic or urinary tract infections, changes in urinary habits.

• Cardiovascular: Symptoms of hypertension or heart disease, as these are more common in people with gout.

Past Medical History:

• History of diseases associated with gout like hypertension, diabetes, hyperlipidemia, kidney disease.

• Evidence of comorbid conditions including obesity, metabolic syndrome, or sleep apnea.

Past Surgical History:

• History of surgery for gout such as tophi removal or joint replacement.

Drug History:

• Use of medications that might trigger gout, such as diuretics, aspirin, cyclosporine, or niacin.

• History of use of urate-lowering therapies like allopurinol, febuxostat or uricosurics.

• Compliance to prescribed medications and response.

Family History:

• Presence of gout or other related conditions like kidney stones or early-onset hypertension in close relatives.

Personal History:

• Dietary habits especially high consumption of purine-rich foods (like red meat and shellfish), sugary drinks, and alcohol (especially beer).

• Exercise habits, sedentary lifestyle could contribute to obesity and hence gout.

Social History:

• Occupational status: jobs that may have contributed to a sedentary lifestyle or poor diet.

• Socio-economic status: access to healthcare, adherence to medication and diet control.

• Alcohol intake and type of alcohol consumed: beer is particularly associated with gout.

Physical Examination

General Examination:

• Tophi noted on outer ear edge, elbows, or fingers indicating longstanding gout.

• Gouty arthritis may cause visible joint swelling and deformity, particularly in the hands and feet.

• Presence of Heberden's nodes or Bouchard's nodes might suggest co-existing osteoarthritis.

• Patient may display signs of discomfort or pain while moving due to joint involvement.

Examination of Hands and Arms:

• Presence of tophi on the fingers, wrists or elbows. These are firm, chalky collections of uric acid crystals, commonly found in chronic gout.

• Joint swelling or deformities due to chronic arthritis.

• Bouchard's nodes or Heberden's nodes suggesting co-existing osteoarthritis.

Examination of Mouth and Neck:

• Presence of tophi in the ear cartilage.

• Examination of the neck may reveal signs of comorbid conditions such as obesity or signs suggesting sleep apnea.

Cardiac Examination:

• Evidence of hypertension (like left ventricular hypertrophy) or heart disease, which are commonly associated with gout.

Respiratory Examination:

• Findings consistent with sleep apnea, such as obesity and increased neck circumference.

Abdominal Examination:

• Presence of renal calculi may cause tenderness in the renal angle or lower abdomen.

• Examination may reveal signs of obesity.

Neurological Examination:

• Typically not involved unless gouty tophi compress nerves.

Additional Examination:

• Gouty tophi or joint deformities in other joints such as knees, ankles, or toes.

• Signs of skin inflammation or infection over the tophi.

• The examination of other systems would be guided by the comorbidities, if any.

Investigations

Laboratory Investigations:

• Serum uric acid level: Elevated levels may be found but a normal level does not rule out gout, as it might be normal during an acute attack.

• Full blood count: To assess for evidence of inflammation, such as raised white cell count.

• Renal function tests: Gout can be associated with chronic kidney disease.

• Liver function tests: To rule out liver disease which may affect urate metabolism.

• Fasting blood glucose and HbA1c: Gout can be associated with diabetes.

• Lipid profile: Gout can be associated with hyperlipidemia.

• ESR and CRP: These markers of inflammation may be raised in acute gout attacks.

• Synovial fluid analysis: To look for monosodium urate crystals which is diagnostic for gout.

Imaging Investigations:

• X-ray of affected joints: In chronic cases, 'punched-out' erosions with overhanging edges may be seen, although gout may not always be seen on X-ray.

• Ultrasound or Dual-energy CT: May show urate deposits within joints and tophi, more sensitive than traditional X-ray.

• Kidney ultrasound: To assess for urate nephropathy or kidney stones.

Invasive Investigations:

• Joint aspiration and synovial fluid analysis: The presence of negatively birefringent monosodium urate crystals confirms the diagnosis of gout.

Other Tests:

• Cardiovascular risk assessment: Given the strong association between gout and cardiovascular disease, a full cardiovascular risk assessment including blood pressure measurement may be required.

Management

General Management:

• Lifestyle advice: Recommend a diet low in purines, limit alcohol intake, maintain hydration, and encourage weight loss if overweight.

• Review and management of associated conditions: Hypertension, hyperlipidemia, diabetes, obesity, kidney disease.

Medical Management:

• Acute attack: NSAIDs like indomethacin, corticosteroids, or colchicine to relieve symptoms.

• Urate-lowering therapy: Allopurinol or febuxostat, typically started after the acute attack has resolved.

• Prophylaxis against acute attacks during initiation of urate-lowering therapy: Colchicine or low-dose NSAIDs.

• Adjust medication according to renal function.

Surgical Management:

• Surgical removal of large tophi that are causing pain, infection, or are not responding to medical management.

• Joint replacement surgery for severely damaged joints due to chronic gouty arthritis.

Other:

• Patient education: Ensure understanding of the disease, its triggers, and the importance of compliance with medication and lifestyle measures.

• Regular follow-up: Monitor serum uric acid levels and adjust therapy accordingly.

• Multidisciplinary approach: Involvement of dietitian, physiotherapist for dietary advice and improving joint function.