Severe tophaceous gout affecting joints and skin

A 40-year-old woman was admitted for polyarthralgia and recurrent swelling over 7 years. She had noted multiple white hard swelling, developed within a year. There was no family history of gout. She had been taking oral prednisone (20 mg/day) as self-medication for over a year. Physical examination revealed multiple tophi on hands, feet, elbows, and knees. Some were on the skin, ulcerated, and discharged white chalky material (A,B,C,D). Laboratory findings showed elevated serum uric acid (124 mg/l) with normal renal function. Radiological examination of both hands and feet showed soft-tissue swelling with minor destructions. Musculoskeletal ultrasound found both a snowstorm and double contour signs. The patient was treated with allopurinol gradually increased up to 300 mg/day associated with colchicine at 1 mg/day and progressive reduction of corticosteroids. After 1 month of convenient diet and regular treatment, serum uric acid level decreased to 60 mg/l. Tophi dissolution is a slow process that will require continuous long-term therapy.