Tofo gotoso en dorso nasal: reporte de caso / Nasal gouty tophus: case report

La gota es el trastorno del metabolismo de las purinas que se caracteriza por acumulación de ácido úrico por aumento de su producción o por disminución de su excreción. Con el paso del tiempo, el exceso de urato monosódico permite que se deposite en diferentes tejidos del organismo; siendo particularmente infrecuente la presentación de tofos a nivel facial. Paciente masculino adulto de 56 años, con antecedente de gota hace 38 años y presencia de tofos gotosos a nivel de miembros superiores e inferiores que acude por cuadro de 4 años de evolución de lesión indurada, levemente dolorosa a nivel de tercio medio de dorso nasal que ha ido aumentando de tamaño, que causa deformidad de pirámide nasal y leve sensación de obstrucción nasal bilateral por lo que se planifica resolución quirúrgica. El análisis histopatológico de las muestras enviadas bajo exéresis quirúrgica confirma que tejido enviado corresponde a tofo gotoso. Los tofos gotosos pueden aparecer en diferentes tejidos, como cartílagos, membranas y líquido sinovial, superficies articulares, siendo excepcionalmente raro, en el miocardio, válvulas mitral y aórtica, ojos, nariz y médula espinal. El lugar de presentación puede ser muy variable, al igual que su tamaño

Gout is a purine metabolism disorder characterized by accumulation of uric acid due to increased production or decreased excretion. Over time, excess monosodium urate allows it to be accumulated in different body tissues, although the occurrence in the facial area is particularly infrequent. A 56- year-old male patient with a gout antecedent from 38 years ago that presented gouty tophi at the level of the upper and lower limbs seek medical advice due to an indurated slightly painful lesion at the level of the middle third of the nasal dorsum that started 4 years before and has been increasing in size. The lesion was causing nasal pyramid deformity and a slight sensation of bilateral nasal obstruction, for which surgical resolution is planned. The histopathological analysis of the samples sent under surgical exeresis confirms that the tissue sample corresponds to gouty tophi. Gouty tophi can appear in different tissues, such as cartilage, membranes and synovial fluid, joint surfaces, being exceptionally rare in the myocardium, mitral and aortic valves, eyes, nose and spinal cord. The place of presentation can be very variable, as well as its size

The clinical characteristic and risk factors of subcutaneous tophus among hospitalized gout patients / 中国医师进修杂志

Objective:To explore the clinical characteristic and risk factors of subcutaneous tophus among hospitalized gout patients.Methods:The clinical data of 646 inpatients with gout from April 2014 to December 2019 in Tianjin Medical University Chu Hsien-I Memorial Hospital were retrospectively analyzed. The patients were divided into tophus group (172 cases) and non-tophus group (474 cases) according to the presence of subcutaneous tophus. The body height, body mass, waist circumference, hip circumference and blood pressure were measured. The total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), urea nitrogen, creatinine, uric acid and C-reactive protein (CRP) were detected; urine was collected for 24 h to detect uric acid. The body mass index (BMI), estimated glomerular filtration rate (eGFR) and uric acid excretion fraction (FUA) were counted. Binary Logistic regression analysis was used to analyze the independent risk factors of subcutaneous tophus among hospitalized gout patients.Results:The proportion of male, course of disease, number of joint involved in attack, rate of smoking history, rate of drinking history, smoking amount, alcohol consumption volume, length of time spent drinking, length of time spent smoking, LDL-C, urea nitrogen, serum creatinine and serum uric acid in tophus group were significantly higher than those in non-tophus group: 98.84% (170/172) vs. 94.09% (446/474), 10 (5, 16) years vs. 5 (2, 9) years, 6 (4, 8) joints vs. 3 (2, 5) joints, 66.86% (115/172) vs. 58.44% (277/474), 65.70% (113/172) vs. 57.38% (272/474), 11 (0, 20) cigarettes /d vs. 10 (0, 20) cigarettes/d, 100 (0, 250) ml/d vs. 50 (0, 162) ml/d, 10 (0, 26) years vs. 0 (0, 20) years, 20 (0, 30) years vs. 10 (0, 20) years, (3.44 ± 0.98) mmol/L vs. (3.25 ± 0.97) mmol/L, 5.81 (4.61, 7.46) mmol/L vs. 5.38 (4.39, 6.66) mmol/L, 89.4 (74.3, 107.5) μmol/L vs. 85.1 (72.5, 98.9) μmol/L and 514.4 (452.9, 595.2) μmol/L vs. 499.0 (404.8, 572.4), the onset age, red blood cell, hemoglobin and eGFR were significantly lower than those in non-tophus group: (37.78 ± 10.56) years old vs. (40.17 ± 13.06) years old, (4.72 ± 0.74) × 10 9/L vs. (4.88 ± 0.56) × 10 9/L, (141.15 ± 17.19) g/L vs. (146.00 ± 13.06) g/L and 87.7 (65.9, 108.4) ml/min vs. 93.3 (75.9, 113.1) ml/min, and there were statistical differences ( P<0.05 or <0.01); there were no statistical differences in family history of diabetes, family history of hypertension, family history of gout, BMI, waist-hip ratio, blood pressure, FUA, white blood cell, TC, TG, HDL-C and CRP between 2 groups ( P>0.05). The patients were grouped according to the course of disease, the incidences of tophus in patients with course of disease ≤5.0 years, 5.1 to 10.0 years and >10.0 years were 15.34% (50/326), 27.67% (44/159) and 48.45% (78/161), and there was statistical difference ( χ2 = 60.59, P<0.01); the patients were grouped according to the quartiles of serum uric acid, the incidences of tophus in patients with serum uric acid <424.05 μmol/L, 424.05 to 505.24 μmol/L, 505.25 to 576.17 μmol/L and ≥576.18 μmol/L were 14.91% (24/161), 32.72% (53/162), 29.01% (47/162) and 29.81% (48/161), and there was statistical difference ( χ2 = 15.70, P<0.01). Binary Logistic regression analysis result showed that the course of gout, smoking amount, number of joint involved in attack, serum uric acid and LDL-C were the independent risk factors of subcutaneous tophus among hospitalized gout patients ( OR = 1.069, 1.020, 1.317, 1.002 and 1.262; 95% CI 1.032 to 1.097, 1.006 to 1.032, 1.223 to 1.417, 1.000 to 1.003 and 1.033 to 1.541; P<0.01 or <0.05). Conclusions:The duration of disease, number of involved joint, serum uric acid level, unhealthy lifestyles and lipid metabolism disorders are the independent risk factors of subcutaneous tophus among hospitalized gout patients.

Gota tofácea crónica en un adulto / Chronic tophaceous gout in an adult

Se presenta el caso clínico de un paciente de 57 años de edad, mestizo, con antecedentes de artritis reumatoidea y gota, quien acude a la consulta especializada de Dermatología del Hospital Clinicoquirúrgico Docente Celia Sánchez Manduley de Manzanillo, provincia de Granma, por presentar lesiones nodulares dolorosas diseminadas. Se realizaron estudios complementarios y biopsia de piel, cuyos resultados permitieron diagnosticar una gota tofácea crónica. El paciente llevaba tratamiento medicamentoso con prednisona, colchicina y metrotexate, pero luego de discutir el caso con los especialistas en medicina interna y reumatología se decidió sustituir la colchicina por el alopurinol.

The case report of a 57 year-old mestizo patient, is presented with a history of rheumatoid arthritis and gout who visited the specialized Dermatology department of Celia Sánchez Manduley Teaching Clinical-Surgical Hospital in Manzanillo, Granma province, for presenting disseminated painful nodular lesions. Complementary studies and skin biopsy were carried out which results allowed to diagnose a chronic . The patient was under drugs treatment with prednisona, colchicina and metrotexate, but after discussing the case with the specialists in internal medicine and rheumatology it was decided to sustitute colchicina by alopurinol.

Structure and component analysis of uratoma around joint / 局解手术学杂志

Objective To analyze the structure and component of gouty tophus around joint, and provide basis to select solvent of gouty tophus and surgical cleaning method.Methods The sample of gouty tophus were obtained from 6 patients in 187 hospital of PLA from January2016 to December 2017, which were rinsed by distilled water, and then dried and accepted other dispose.The sample were analyzed by Fourier Transform Infrared Spectroscopy (FTIR), scanning electron microscope and thermal gravimetric analyzer.Results Sodium urate was the main component of the uratoma, the proportion was 56％;the organic component was about 14％of the uratoma.The microstructure of the uratoma under scanning electron microscope have two forms, the one looks like column crystal and the other like granules head up to lump.Conclusion The main component of the gouty tophus are sodium urate and organic tissues, the possible solvent should react on the both of them.

Therapeutic Effect of Heat-clearing and Diuresis-promoting Herbs Combined with Febuxostat for Chronic Gout / 广州中医药大学学报

Objective To investigate the clinical efficacy of heat-clearing and diuresis-promoting herbal formula Tongfeng Recipe in treating damp-turbidity-heat accumulation type of gout with tophus. Methods Sixty qualified patients were randomized into treatment group and control group, 30 cases in each group. The control group was given oral use of Febuxostat Tablets, and the treatment group was given Tongfeng Recipe combined with Febuxostat Tablets. After treatment for 6 months, we compared the changes of serum uric acid, the maximum diameter of the tophi, attack frequency of gout, scores of traditional Chinese medicine (TCM) syndromes, and adverse reaction in the two groups. Results (1) During the trial, 2 cases from the treatment group and 3 from the control group were lost to follow-up, and the final included case number of the treatment group and control group was 28, 27 respectively. (2) After treatment, the serum uric acid level in the two groups was decreased (P<0.01 compared with that before treatment), and the decrease in the treatment group was superior to that in the control group (P<0.05). (3) After treatment, the percentage of patients with serum uric acid less than 60mg/L in the treatment group and control group was 96.43％, 77.78％ respectively, the difference being significant(P<0.05).(4) After treatment, the maximum diameter of the tophi was reduced in the two groups(P<0.05 compared with that before treatment), and the decrease in the treatment group was superior to that in the control group (P<0.05). (5) After treatment, the scores of TCM syndromes in the two groups were markedly improved (P < 0.01 compared with those before treatment) , and the improvement in the treatment group was superior to that in the control group (P < 0.05). (6) During the treatment, acute attack of gout occurred in one case of the treatment group and in 7 cases of the control group, the difference being significant (P<0.05). The treatment group had 4 cases of diarrhea and one case of hepatic function injury, and the control group had 3 cases of diarrhea and one case of hepatic function injury , the difference being insignificant between the two groups (P > 0.05). Conclusion Heat-clearing and diuresis-promoting herbal formula Tongfeng Recipe exerts certain effect in treating damp-turbidity-heat accumulation type of gout with tophus, and the recipe is effective on decreasing serum uric acid, preventing the acute attack of gout induced by anti-uric acid treatment, and improving TCM syndromes.

Analysis of risk factors for susceptibility of subcutaneous tophi in people with gout / 中华内分泌代谢杂志

Objective To discuss the risk factors for susceptibility of subcutaneous tophi with an aim to provide clinical evidence for the prevention and treatment of tophi.Methods A total of 5 321 cases of gout patients whose course of disease was less than 10 years were selected and divided into two groups according to whether a subcutaneous tophus was present. The clinical information was collected and relevant biochemical indices were detected.Results There were significant differences in the ratios of regular exercise, involvement of upper limb joints, combining renal insufficiency, kidney stone and coronary heart disease between the tophus group and the non-tophus group(P0.05). Further logistic regression analysis indicated that disease duration, a large number of joints involved, the involvement of upper limb joints, combining kidney stones, higher serum uric acid level, and higher diastolic pressure were risk factors of the early onset of subcutaneous tophi, while regular exercise and body mass index were protective factors.Conclusion Patients with long duration, high serum level of uric acid, a large number of joints involved, upper limb joint involved, kidney stones, and hypertension were more likely to develop subcutaneous tophi. These risk factors should be intervened actively in clinic.

Progress on diagnosis and treatment of tophus / 中国骨伤

Tophi deposit in the peripheral bone joints or soft tissues are formed by uric acid and urate crystal. It does not only affect local appearance but also destroy the bone and joint structure, resulting in loss of function. Traditional medical treatment is an effective way to control the hyperuricemia, but it is ineffective to tophus. Surgery is a relatively effective method for the treatment of tophus. It can successfully reduces the content of uric acid in the body and improves the limbs function, but it causes surgical trauma and complications. As new medicine, Urcase is a hot spot in the present study. It can not only control the blood uric acid level but also dissolve part of tophus. But the cost is higher than traditional medicines. There is still dispute in treatment for advanced tophus.

Tofo gotoso en la mano / Gout tophus in the hand

Se presenta el caso clínico de un paciente de 54 años de edad, con antecedentes de gota desde hacía varios años, y afectación de la piel por gota tofácea crónica, quien acudió a la consulta de Ortopedia y Traumatología del Centro de Diagnóstico Integral con quirófano "Calilo García" en el Estado de Apure, de la República Bolivariana de Venezuela, por presentar lesión microquística dolorosa en el dorso de la falange distal del dedo índice de la mano derecha. El diagnóstico se confirmó mediante el estudio histopatológico del tumor.

The case report of a 54 years patient, with a history of gout for several years, and damage of the skin due to chronic gout tophus is presented, who went to the Orthopedics and Traumatology Department of "Calilo García" Center for Comprehensive Diagnosis with operating room in the Apure State, Bolivarian Republic of Venezuela, for a microcystic painful lesion in the back of the distal phalange of the index finger of the right hand. The diagnosis was confirmed by means of the histopatological study of the tumor.

Diagnostic utility of FNAC in gouty tophi with review of literature.

Periarticular nodules have the variety of differential diagnosis including inflammatory to neoplastic conditions. Amongst these, gouty tophus is an important differential diagnosis. Fine needle aspiration cytology (FNAC) is a valuable diagnostic tool for the diagnosis of periarticular nodules. We presented here a case of 48 years old male with multiple soft tissue nodules in extremities. Case was evaluated clinically and FNAC was advised. Fine needle aspiration revealed chalky white aspirate. The case was studied and data was collected in month of October 2013. After staining the smear with Hematoxylin and Eosin (H&E), needle shaped crystals were seen in amorphous granular debris. Diagnosis of gouty tophi was made. On further workup, serum uric acid levels were found to be high and a diagnosis of gout was established. FNAC is an easy, minimally invasive and cost effective procedure for diagnosing gouty tophus and is replacing biopsy for the diagnosis of gouty tophus.

Carpal Tunnel Syndrome Associated with Tophaceous Deposition in Flexor Digitorum Tendons

Carpal tunnel syndrome is the most common peripheral entrapment neuropathy. We report on the first Korean case of carpal tunnel syndrome induced by tophaceous deposition in flexor digitorum tendons of a patient with chronic gout. A 63-year-old male suffered from numbness, decreased sensation over both median nerve distribution, and weakness of thenar muscle for 3 years. Physical examinations revealed positive Tinel's sign and Phalen's test and thenar qjmuscle atrophy was found on both hands. In nerve conduction study, there was no action potential of the sensory and motor of the bilateral median nerve. Ultrasonography showed increased cross-sectional area of median nerve due to tophaceous deposition in flexor digitorum tendons in the carpal tunnel. Dual-energy computed tomography showed diffuse multifocal green color coding tophaceous deposition within the carpal tunnel. His neuropathic symptoms improved after injection of triamcinolone into the carpal tunnel and administration of oral medication including non-steroidal anti-inflammatory drugs and colchicine.

Image analysis of the distribution of tophus in ankle joint and tarsal joint / 实用放射学杂志

Objective To analyze the distribution of tophus in ankle and tarsal joints by multislice spiral computed tomography (MSCT)and to explore the pathogenesis of gout.Methods 34 patients with a documented diagnosis of gout underwent CT examina-tion of bilateral ankle and tarsal joints,and 55 ankle and tarsal joints were observed tophus.The sites of tophus deposition were cate-gorized into groups of ligament,tendon and joint in order to record and analyze.Results The tophus were showed at the anterior talofibular ligament (n=38),the medial ligament (the site of talus and calcaneus)(n=30)and the interosseous talocalcaneal liga-ment (n=29)(P <0.05)in the group of ligament;at achilles tendon (n= 18),followed by tibialis posterior tendon (n= 7)(P <0.05)in the group of tendon;at articulations intercuneiformes (n=1 5)and inferior tibiofibular articulation (n= 10)(P <0.05 )in the group of joint.Conclusion In ankle and tarsal joints,tophus is commonly deposited at the anterior talofibular ligament,at the achilles tendon and the articulationes intercuneiformes.

Gota axial / Gout in the spine

A gota axial pode afetar todos os segmentos da coluna vertebral. Ela se manifesta como dor nas costas, dor associada com sintomas neurológicos, e como comprometimento neurológico sem dor em 17,9%, 75,8% e 4,2% dos casos, respectivamente. Essas manifestações foram a primeira apresentação da gota em muitos pacientes. Embora radiografias, bem como tomografia computadorizada e especialmente ressonância magnética, possam ser muito sugestivos, análises histopatológicas, citológicas e pesquisa de cristais são o padrão ouro de diagnóstico. Na maioria dos casos que envolveram manifestações neurológicas, o paciente foi submetido à cirurgia, levando a resultados satisfatórios. Há, no entanto, alguns relatos de recuperação total após o tratamento clínico habitual para gota, o que sugere que esse tratamento pode ser a opção inicial para os indivíduos com histórico de gota e sinais radiológicos de envolvimento axial.

Axial gout can affect all segments of the spine. It is manifested as back pain, as pain associated with neurological symptoms, and as neurological impairment without pain in 17.9%, 75.8% and 4.2% of cases, respectively. These manifestations were the first presentation of gout in many patients. Although x-rays as well as computed tomography and especially magnetic resonance scans can be very suggestive, histopathological, cytological and crystal analyses are the diagnostic gold standard. In most cases involving neurological manifestations, the patient underwent surgery, leading to satisfactory results. There are, however, some reports of full recovery following the usual clinical treatment for gout, suggesting that such treatment may be the initial option for those subjects with a history of gout and radiological findings of axial involvement.

Tofo intramuscular del vasto externo en el muslo izquierdo / Tophus intramusculaire du vaste externe de la cuisse gauche / Intramuscular tophus in the external vastus of the left thigh

Introducción: la gota es una alteración del metabolismo de las purinas caracterizada por hiperuricemia, con rara implicación de la región del muslo y en específico intramuscular. Objetivo: presentar este caso por la rareza de este tipo de tumoración en la porción intramuscular. Descripción: se presentó el caso clínico de un varón de 64 años, sin el diagnóstico previo de gota, que fue intervenido quirúrgicamente por una masa tumoral de partes blandas en el muslo izquierdo, con resección muscular en bloque. Se hizo una revisión de la literatura y se analizó su presentación clínica, hallazgos histológicos, pruebas diagnósticas de imagen y tratamiento terapéutico. Conclusiones: el estudio anatomopatológico confirmó el diagnóstico de tofo gotoso intramuscular del músculo vasto externo. Actualmente, el paciente se encuentra libre de síntomas y en seguimiento por el servicio de reumatología y de ortopedia.

Introduction: gout is a disorder of purine metabolism characterized by hyperuricemia, with rare involvement of the thigh region, let alone intramuscular involvement. Objective: present this case due to the rarity of this type of tumor in the intramuscular portion. Description: a clinical case is presented of a male 64-year-old patient with no prior gout diagnosis, who had been operated on for a tumor mass of soft parts in the left thigh with en bloc muscle resection. A bibliographic review was conducted and an analysis carried out of the clinical presentation, histological findings, diagnostic imaging tests and therapeutic treatment. Conclusions: anatomopathological examination confirmed the diagnosis of intramuscular gout tophus of the external vastus muscle. At present the patient is free of symptoms and is being followed-up by the rheumatology and orthopedics service.

Introduction: la goutte est une altération du métabolisme des purines, caractérisée par une hiperuricémie et une rare implication de la région de la cuisse, spécifiquement de la région intramusculaire. Objectif: présenter un cas manifestant la rareté de ce type de tumeur sur la portion intramusculaire. Description: le cas d'un patient du sexe masculin, âgé de 64 ans, sans diagnostic antérieur de goutte, traité chirurgicalement par résection musculaire en bloc d'une masse tumorale des parties molles de sa cuisse gauche, est présenté. Une révision de la littérature est effectuée, et sa présentation clinique, les résultats histologiques, les tests diagnostiques par image, et le traitement thérapeutique, sont analysés. Conclusions: le diagnostic de tophus gouteux intramusculaire du muscle vaste externe est confirmé par l'examen anatomopathologique. Le patient est actuellement libre de ces symptômes au suivi du Service de rhumatologie et d'orthopédie.

Gout: Diagnosis and management.

Gout is a heterogeneous group of diseases resulting from monosodium urate (MSU) crystal deposition in tissues or from supersaturation of uric acid in extracellular fluids. Clinical manifestations include 1) Recurrent attacks of articular and periarticular inflammation, also called gouty arthritis; 2) Accumulation of articular, osseous, soft tissue, and cartilaginous crystalline deposits, called tophi; 3) Uric acid calculi in the urinary tract; and 4) Interstitial nephropathy with renal function impairment, called gouty nephropathy. Gout predominantly is a disease of adult men, with a peak incidence in the fifth decade. In women usually found after menopause. The metabolic disorder underlying gout is hyperuricaemia. The duration and magnitude of hyperuricemia directly correlate with the likelihood of developing gouty arthritis and uric acid urolithiasis, and with age at onset of initial clinical gouty manifestations. The urate crystals induce phagocytes and synovial cells to generate and release such mediators as cyclooxygenase and lipoxygenase metabolites of arachidonic acid, phospholipase A2-activating protein, lysosomal proteases, tumor necrosis factor (TNF)-α, interleukin (IL)-1, IL-6, and IL-8. Definitive diagnosis of gout needs the demonstration of MSU crystals in synovial fluid or tophus. Gout is frequently associated with comorbidity such as obesity, hypertension, renal disease and dyslipidaemia. Therapeutic goals include terminating acute attacks; providing rapid, safe relief of pain and inflammation; averting future attacks; and preventing such complications as formation of tophi, kidney stones, and destructive arthropathy. Colchicine, nonsteroidal anti-inflammatory drugs and corticosteroid are drugs used for treating acute gouty arthritis. Colchicine is also used for prophylaxis. Urate lowering drugs also play a role in prophylactic management of gout. With early intervention, careful monitoring, and patient education, the prognosis is excellent.

Gouty Tophus on the Tibial Tuberosity with Accompanied Chemical Cellulitis Localized at the Upper Tibia / 대한류마티스학회지

Gout is characterized by hyperuricemia and recurrent attacks of acute arthritis. Gout is a clinical syndrome resulting from the deposition of urate (monosodium urate monohydrate) crystals. Urate deposition occurs in articular cartilage, subchondral bone, synovial membrane, joint capsule and periarticular tissues, with articular cartilage being especially susceptible. The first metatarsophalangeal joint is commonly involved at presentation and other commonly affected joints are the ankle, knee and tarsal area. Gouty tophus located on the tibial tuberosity has never been reported in korea. We report a case of gouty tophus on the tibial tuberosity with (chemical) cellulitis occurred at the upper tibial area in a 46- year-old man.

A Clinical Study On Gouty Arthritis / 대한류마티스학회지

OBJECTIVE: The gout characterized by hyperuricemia is a disorder of purine metabolism and clinical manifestations were seen such as arthritis and tophi in the subcutaneous fitssues. But clinical symptoms were not correlated with the serum level of uric acid. So we analysis of clinical orthopaeclic manifestations and associated factors in gout. METHODS: We have reviewed the medical records, radiography and clinical results of forty six patients admitted at out department between july 1981 and July 1990. RESULTS AND SUMMARY: 1) OF the forty-six patient, 44 cases(95.6%)were male and two female. The age at initial attack was 47.7 year-old in average, from 13 to 66 year-old. 2) Hyperuricemia was associated with obesity in 17 cases(40%), and hyper-tension in 16 cases(35%). 3) The level of uric acid in serum was 9.7mg/% in average on admission and 5.9mg/% on discharge after treated with allopurinol about 2 weeks. 4) The first metatarsophalangeal joint was involved in 28 cases(60.9%) and the ankle joint in 12 cases. Topbus was observed in 14 cases(30.4%) and they were surgically treated in 10 cases.

A Case of Transepidermal Elimination in Gouty Tophus / 대한피부과학회지

We herein report a case of gout, who was a 45-year-old man and had had multiple various-sized papules or tophi on the helices of ears, hands, elbows, knees, ankles and feet for 10 years. Histopathologic findings of the large tophus of right knee revealed the typical pattern of gout with needle-shaped urate crystal. The phenomenon of iransepidermal elimination was observed in serial sections of histologic speeirnerls, The nsrrow transepidermal channel, lined by pseudoepitheliomstous lips bilaterally, was Eilled with the cellular debris and urate crystal fragments and cornmunicated direotly with the upper dermis. Presumably, transepidermal elirnination in gouty tophus may be the phenomenon whieh could be found rnore commonly than the scarcity of literature.

A Case Report of Severe Form of Gout / 대한정형외과학회잡지

A case of gouty polyarthropathy accompanied with carpal tunnel syndrom is reporte, in a 70 year old man. The patient was treated by removal of tophaceous materials surgically in both knee and right wrist joints for the relief of pain. There was a relatively good result postoperatively in the aspect of pain free motion of joints, but he was died of the complication of gouty nephropathy 4 months later after discharge.