A 5-day history of pain and swelling in the right third finger (A) were the complaints of a 76-year-old man. A few days earlier, another physician had prescribed indomethacin, 25 mg tid, but it had not helped, and the patient believed that his condition had worsened. He had had an attack of gout 5 years before but had not been taking any maintenance medication. The distal interphalangeal (DIP) joint of the affected finger was now erythematous and tender, with chalky subcutaneous deposits. A diagnosis of acute gouty arthritis and gouty tophus was made.
Gout may occur secondary to overproduction of uric acid or reduced excretion of renal urate. When the rate of urate production exceeds the rate of excretion, monosodium urate crystals are deposited, and gouty tophi develop. Tophi most commonly occur on the helix and antihelix of the ear, on the ulnar surface of the forearm, at pressure points (eg, at the Achilles tendon), at DIP articulations, and on the great toe (B).