Gouty Hands
Examination of the Hands – Sequence
 Tophi, joint deformity
 Feel joints for active arthritis
 Palmar erythema, dupytren’s contracture (alcohol), finger pulps for tophi
 Test function – pincer and grip, coarse and fine
 Look at the extensor surface and elbows (olecranon bursae)
 Sallow appearance, dialysis (Renal failure)
 Pinna or helix of the ear
 Pleithoric, parotidmegaly, bleeding and hypertrophic gums
 Look at the feet for joints, deformity, active arthritis, diabetic dermopathy
 Feel the achilles tendon and infrapetallar region
 Request
o Walk patient if feet are involved
o BP
o Urine dipstick for glycosuria, hematuria (stones)
Presentation
Sir, this patient has chronic tophaceous gout affecting his hands and his feet. On
examination of the hands, there is asymmetrical swelling affecting the small joints of the
hands with tophi formation which has resulted in severe deformity of the hands and feet. I
also noticed that these tophi are exuding chalky material. On palpation, there is no
tenderness and joints are not warm to suggest active arthritis. There is wasting of the
intrinsic muscles of the hands. There is also presence of tophi on the extensor aspects of
the forearms, the left olecranon bursae, the right helix/pinna of the ear as well as the
small joints of the feet. I looked for but did not detect any tophi on the achilles tendon or
the infrapetallar region.
In terms of function, he is able to perform pincer and handgrip movement and his
hand function is relatively preserved; able to perform door knob turning and cap a pen, as
well transfer coins and unbutton his shirt.
I noticed that the patient is not obese looking, no DM dermopathy or xanthelasma
as these are a/w gout. There is also no evidence of chronic ethanol ingestion such as
palmar erythema, dupytren’s contracture and parotidomegaly. There is no sallow
appearance to suggest chronic renal failure. I also did not detect any conjunctival pallor
or suffusion, hypertrophic or bleeding gums and patient is not pleithoric which may
suggest presence of lymphoproliferative disease or polycythaemia. There are no psoriatic
skin lesions
I would like to complete the examination by walking to patient to assess function
as I noticed that his feet is affected by gouty arthritis, take his blood pressure as well as a
urinalysis to look for glycosuria as well as hematuria for UA stones and proteinuria for
UA nephropathy. A detailed drug history, dietary history and alcohol consumption.
Questions
What is gout?
Gout is a disorder of purine metabolism, resulting in hyperuricaemia either from
overproduction(75%) or undersecretion of uric acid, resulting in deposition of urate
crystals in the joints or bursae.
Patients typically present with acute monoarthritis of the first MTPJ, with pain
swelling and exquisite tenderness which peaks within hours and lasts for days. It affects
the joints of the lower limbs initially in the majority of patients which includes the MTPJ,
ankles and knees. It can also subsequently affects the joints of the upper limb.
What are the stages of gout?
Acute gouty arthritis
Intercritical period
Chronic tophaceous gout
What does tophi indicate?
Severe, recurrent and chronic gout.
Where are the commonly areas to look for gouty tophi?
Hands, extensor aspect of the forearms, olecranon bursae
Helix if the ears
Toes, Achilles tendons, infrapetaller regions
What are the clinical manifestations of gout?
Asymptomatic hyperuricaemia
Acute arthritis
Chronic, recurrent arthritis
Tophaceous gout
Uric acid nephrolithiasis
Uric acid nephropathy
What are the triggering factors of gout?
Alcohol ingestion
Foods – sweetbreads, liver, kidneys and sardines
Drugs – Thiazide diuretics, aspirin, cyclosporine, pyrazinamide and ethambutol
Dehydration and fasting
Surgery, Trauma
What are the causes of gout?
Primary – associated with obesity, diabetes mellitus, hypertension and high TGs
Secondary
Drugs
Chronic ethanol ingestion
Chronic renal failure
Polycythaemia, lymphoproliferative, myeloproliferative
Psoriasis
How would you investigate?
Definitive investigation would be aspiration of the involved joint, looking for
intracellular deposition of needle-shaped crystals that is negatively birefringent
under polarised light, within leukocytes.
They react with nitric acid and NH4OH to give a purple color (Murexide test)
Blood Ix – Uric acid levels which may be normal during an acute attack
X-ray of the joints may show erosive arthropathy from tophi with overhanging
edges associated with punctuate to diffuse calcification.
How would you manage?
Education and counselling, including dietary advice and avoidance of alcohol
PT/OT if tophaceous gout for preservation of function
Manage associated hypertension and diabetes mellitus
Medications – acute attack and prophylaxis
Surgery – rarely for cosmetic reasons, arthroplasty
How would you treat an acute attack?
NSAIDS – Indomethacin (50mg tds)
Colchicine 2 ways:
0.5mg hrly till GI side effects or max of 5 mg, or
0.5mg tds
Intrarticular steroids (triamcinolone 20mg)
Systemic steroids (Prednisolone 30mg OM and tails over 7-10 days)
How would you prophylax against gouty attacks?
Prophylactic agents used are iniated under colchicine cover which includes:
Xanthine oxidase inhibitor
Allopurinol
New agents – Uricase, febuxostat
Uricosuric acid agents
probenecid or sulfinpyrazone
losartan
fenofibrate
What are the indications for allopurinol?
Recurrent gouty attacks > 3 times a year
Chronic tophaceous gout
Uric acid nephropathy
Persistently high uric acid level
Conditions that may predispose an individual to gouty attacks, prior to
chemotherapy or radiotherapy which may induce tumor lysis
What are the side effects of allopurinol?
Side effects occur in 3-5%
Rash, diarrhea, drug fever
Leucopenia, thrombocytopenia
Allopurinol hypersensitivity syndrome
Erythematous rash, fever, hepatitis, hypereosinophilia and renal
failure
What are the other crystal arthropathy that you know about?
Pseudogout – Acute arthritis resulting from deposition of calcium pyrophosphate
dihydrate crystals in the joints which are rhomboid shaped positively birefringent crystals
under polarised light.
Calcium hydroxyapatite crystals deposition in the large joints such as knees and
shoulders, affecting the elderly.
What are the differential diagnoses?
Septic arthritis
Overlying cellulitis
Trauma
What is your differential diagnosis for chronic tophaceous gout?
Florid tendon xanthomata
Yellow and not chalky
Adherent to tendon and not joint
Does not involve the bursae, ie no olecranon or pinna lesions
No active arthritis