A 68-year-old woman is brought to the clinic by her daughter due to severe pain in her fingers. Her daughter says, "Mom has had horrible problems with her joints for a long time, but she has never tried to get help." The patient adds that her fingers have become more swollen and painful over the last few weeks. She had similar symptoms in her foot last year. She was given an unknown pain pill, but it was ineffective. Medical history is notable for hypertension, hypothyroidism, and early Alzheimer dementia. Vital signs are normal. Examination findings of the hands are shown in the image below. What is the most likely diagnosis in this patient?

Question

A 68-year-old woman is brought to the clinic by her daughter due to severe pain in her fingers.  Her daughter says, "Mom has had horrible problems with her joints for a long time, but she has never tried to get help."  The patient adds that her fingers have become more swollen and painful over the last few weeks.  She had similar symptoms in her foot last year.  She was given an unknown pain pill, but it was ineffective.  Medical history is notable for hypertension, hypothyroidism, and early Alzheimer dementia.  Vital signs are normal.  Examination findings of the hands are shown in the image below.  What is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient with multiple white nodules in the hands and a history of painful arthritis in the fingers and feet has tophaceous gout. In most cases, gout is characterized by hyperuricemia and precipitation of uric acid crystals in the joints, leading to episodic monoarticular arthritis (especially in the first metatarsophalangeal joint and knee). The diagnosis is confirmed with arthrocentesis showing an inflammatory effusion with uric acid crystals. Urate crystals may also deposit in the soft tissues, forming tumors known as tophi. Tophi can ulcerate and drain a chalky material. Uric acid tophi are virtually pathognomonic for gout, and even in the absence of microscopic confirmation of crystals, the diagnosis can be made provisionally in patients with visible tophi and a history of episodic monoarthritis. An elevated serum uric acid level is nonspecific but can also contribute to the diagnosis. (Choice A) Calcinosis cutis is characterized by deposition of calcium and phosphorus in the skin. It presents with scattered whitish papules, plaques, or nodules. This patient's history of painful arthritis is more typical for gout. Calcinosis cutis (Choice B) Chondrosarcomas are bone tumors occurring in the 5th or 6th decade of life. They most commonly affect the pelvis, femur, or proximal humerus and would likely not be as multifocal and bilateral as the disease pictured. (Choice D) Severe osteoarthritis can produce Heberden and Bouchard nodes, which are hard, bony nodules over the distal and proximal interphalangeal joints, respectively. This patient's tophi involving several joint spaces and soft tissue structures are more consistent with gout. osteoarthritis (Choice E) Psoriatic arthritis can present with distal interphalangeal joint arthritis, asymmetric oligoarthritis, symmetric polyarthritis, spondyloarthropathy, or aggressively destructive arthritis mutilans. Most patients have established psoriasis, and nail changes (eg, pitting) are common. Psoriatic arthritis (Choice F) Rheumatoid nodules are firm, flesh-colored, and nontender. They typically occur over pressure points such as the elbow and extensor surface of the proximal ulna. Rheumatoid nodules Educational objective: In chronic tophaceous gout, urate crystals can be deposited in the skin, resulting in the formation of tumors with a chalky white appearance.

A 68-Year-Old Woman Is Brought to the Clinic by Her