(BMJ)—A 56-yo man w/ a 7-yr hx of polyarthritis and w/ heavy alcohol use presented w/ multiple subcutaneous nodules on his body and deformities of his hands and feet. Exam: hard, painless, partly ulcerated nodules near joints, tendons, and bursae, w/ restricted extension of the L index finger and L knee. What is the dx?
Rheumatoid arthritis
Xanthomas
Chondrocalcinosis
Tophaceous gout
Dupuytren dz
You are correct. Chronic enlargement of generalized subcutaneous elastic nodules in someone w/ destructive arthritis and high alcohol intake is suggestive of tophaceous gout. The pt had an elevated serum urate and was negative for rheumatoid factor. Nodule aspirate confirmed urate crystals. Polyarthritis w/ asymmetry and asynchrony makes RA less likely. The pt was started on allopurinol and analgesics, but he developed a rash due to allopurinol and was switched to febuxostat. He was also advised to stop alcohol use and was offered social assistance. His serum urate level normalized, and the tophi regressed.

BMJ 2019;365:l1344