Statistics from Altmetric.com
A 38 year old female owner of a fashion shop presented at the rheumatology outpatient clinic because of intense pain and nodular lesions in her hands (fig 1A). She had a 1 year history of pain and multiple small intradermal deposits, with drainage of white chalky material. She had been initially considered to have an infection owing to the presence of a pyogenic pustule. Because of this, she had been treated with several courses of antibiotics (oral cloxacillin for 2 weeks and then oral amoxicillin plus clavulanic acid for another 2 weeks) draining a thick material, but not frank pus. At the outpatient clinic a needle aspiration obtained a thick white matter. Cultures were sterile and the material contained numerous monosodium urate crystals. She was diagnosed as having intradermal tophaceous gout.
Tophaceous gout is an unusual feature in a young woman.1,2 In these cases a careful search for secondary conditions needs to be carried out. Our patient had a 3 year history of intense fear of gaining weight or becoming fat, subjective disturbance in her body shape “feeling fat”, and 1 year before diagnosis she had amenorrhoea and constipation. She also admitted excessive ingestion of laxatives and diuretic abuse. At diagnosis her body fat was undetectable, and the bones protruded through the skin. Her height was 163 cm and her weight 55 kg (body mass index was 20.7). Our patient had a medical history consistent with anorexia nervosa.
Laboratory determinations disclosed anaemia (haemoglobin 99 mg/l), leucocytosis (17×109/l), and 402×109 platelets/l. A routine blood biochemistry profile yielded glucose 5.9 mmol/l, creatinine 90 μmol/l, urea nitrogen 16.0 mmol/l, sodium 138 mmol/l, potassium 2.2 mmol/l, and uric acid 456 μmol/l. The 24 hour urate clearance was clearly low (3.2 ml/min) and the 24 hour uric acid excretion was 1.6 mmol/day. Thyroid stimulating hormone and thyroxine (T4) levels were normal. Follicle stimulating hormone (14.8 U/l), luteinising hormone (8.2 U/l), and 17 β-estradiol (150 pmol/l) were within normal ranges. Purine enzyme studies, including hypoxanthine guanine phosphoribosyl transferase, adenine phosphoribosyl transferase, and phosphoribosyl pyrophosphate synthetase, were normal. Evaluation showed glucose-6-phosphatase deficiency was also normal. There was no history of exposure to lead. Treatment with allopurinol was started and 9 months later total resolution of the intradermal tophi was achieved (fig 1B).
A number of unusual cutaneous manifestations of chronic gout have been reported.3 As observed in our patient, deposition of urate crystals in the skin can take the form of intradermal, superficial collections of white tophaceous material resembling pus. Aspiration of the nodular collection demonstrating monosodium urate is the preferred technique to achieve a precise diagnosis.1,2
In cases such as our patient, once a diagnosis of chronic tophaceous gout is made, a secondary condition must be excluded.1,2,4 Premenopausal gout is commonly associated with obesity, renal insufficiency, and hypertension. However, Hayem et al report three cases of tophaceous gout affecting premenopausal women and the only precipitating factor was the overuse of furosemide. In their cases, the authors highlighted the importance of a careful search for hidden diuretic abuse.4 Uric acid is primarily excreted by the kidney, and certain drugs including diuretic agents can reduce the excretion of uric acid. No specific tests exist for a diagnosis of anorexia nervosa. Cultural issues, occupation, and body image are important factors in this condition.5 In our case a dysmorphophobia led to inadequate nutrition and an excessive consumption of diuretics. With this case we would like to emphasise that in Western countries, where culture and body image play an important role in eating disorders,6 the diagnosis of tophaceous gout in a young woman should require a psychological evaluation to exclude a medical history consistent with anorexia nervosa.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.