In patients with gout, control of hyperuricemia with behavioural modification and medication is crucial to prevent the development of tophi.
Ulcers caused by tophaceous gout are rare but extremely difficult to treat, and are very debilitating. Although there is no investigative literature on the topic, from our experience and prior case reports, treatment involves antihyperuricemic agents, intensive wound care, close monitoring for signs of infection and, possibly, surgery.
Chronic tophaceous gout is often present with multiple comorbidities, which create a Therapeutic challenge, especially renal failure. Options include febuxostat and uricase agents for patients with mild–moderate renal failure, however, it is unclear if these agents are appropriate in severe renal failure.
Patients with tophaceous gout rarely develop ulcers, but when they do occur, these ulcers can be difficult to treat. Little is known about these types of ulcers — from development to diagnosis and treatment.
This case report, published in the August 3 online issue of BMJ Case Reports, reviews the care and outcome of a patient with ulcerated tophaceous gout.
The researchers, led by Kumar Sukhdeo, MD, PhD, from Case Western Reserve University School of Medicine in Cleveland, reviewed the case of a 60-year-old white man with a long-standing history of poorly controlled polyarticular tophaceous gout complicated by tophaceous ulcers and associated cellulitis.
The patient was noncompliant with his therapeutic regimen.
"On the basis of our literature review, there are no investigational studies regarding tophaceous ulcers, thus little is known about their epidemiology, pathophysiology, clinical course, diagnosis and treatment,” wrote the authors of the report.
Because of its rarity, there are no treatment guidelines for this type of ulcer. The report cites four case reports based on seven patients with ulcerative gout, two of which had ulcers in the upper extremities. None of the seven patients reported numbness, difficulty moving the affected limbs, or experienced severe cellulitis with hemorrhagic bullae.
He presented with swelling, erythema, tingling, numbness, extreme pain and restricted movement of his left forearm and hand. The patient’s medical history included:
- Stage 3 chronic kidney disease
- Type II diabetes mellitus
- Chronic venous insufficiency
- Atrial fibrillation
- The patient was also a former smoker with a prior history of alcohol and cocaine abuse
The patient’s medications included:
- Morphine sustained-release tablets
Assessment, Treatment, Outcomes
With the exception of tachycardia, all vital signs were normal on admission. The left upper forearm and hand were diffusely warm and erythematous, with three hemorrhagic bullae on the ventral forearm and palm, and no palpable pulses in the extremity. Presuming sepsis, the patient was given IV vancomycin and ceftriaxone. Wound cultures showed oxacillin-resistant Staphylococcus hominis; blood cultures were negative. Wound treatment included wrapping the extremity with silver sulfadiazine medicated wraps.
The patient responded to the antibiotics and kidney function improved, the erythema lessened, and the bullae ruptured. The pain, numbness and difficulty with movement remained unchanged.
The patient developed C. difficile infection while hospitalized. After nine days, he was discharged to a nursing facility where he continued to receive treatment. He was readmitted to the hospital 37 days from initial admission because of increased erythema and pain in the same extremity.
The erythema and tophaceous ulcers were smaller than previously. A thick, yellow exudate was expressed from all the ulcers. Wound cultures grew skin flora. Two ulcers on the forearm were connected subcutaneously. The patient also experienced an acute gout flare in the right upper extremity during this period.
Blood test findings included:
- Elevated creatinine from baseline (3 mg/dL)
- Anemia (hemoglobin 8.3 g/dL)
- Mean corpuscle volume 90 fL
- 3.68 percent reticulocytes
- Haptoglobin less than 6 mg/dL
- Lactate dehydrogenase 237 U/L
- Hyperuricemia (10.3 mg/dL)
- Erythrocyte sedimentation rate 111 mm/h
- C reactive protein 5.8 mg/dL
- Blood cultures: no growth
Intravenous fluids were administered and the patient’s kidney function improved. Further wound treatment to the left extremity was changed to medical-grade honey and he was discharged back to the nursing facility.
Severe pain, decreased sensation, and difficulty moving the limb continued, but the patient’s kidney function and hemoglobin stabilized. The authors pointed out that common comorbidities, such as peripheral vascular disease and diabetes, can make gout-related wound healing more difficult.
Techniques to manage the ulcers include:
- Classic curettage and debridement
- Skin grafting
- Hydrogel dressings
- Silver-containing wound dressings
- Heterologous lyophilized collagen
- Citric acid ointment
- Medical-grade honey
“As was illustrated in our patient, tophaceous ulcers are not only difficult to treat, but are also extremely debilitating. Our patient has chronic pain requiring opiate medications, decreased functionality of his limb and diminished sensation in this area,” the authors wrote.
The authors suggest that in addition to finding better ways to manage severe tophaceous gout and renal failure, more research should be aimed towards better identification, diagnosis and treatment.