A 39-year-old Hispanic male with no known medical history presented with progressive pain and swelling in multiple bilateral hand joints, elbows, and knees for the last 5 years with intermittent flare ups, associated with prolonged morning stiffness. He had difficulty making a fist and ambulating. He denied any chronic medications, red meat, or seafood intake but consumed 4 beers/day few days a week for last several years. On exam, synovitis was present in bilateral several proximal interphalangeal (PIP) joints, wrists, elbows, and knees. Range of motion was severely restricted in bilateral wrists with poor fist formation. He had nontender raised pearly nodular rashes on extensor aspects of arms, legs, and anterior abdomen for more than a year (Figures 1 and 2). Large subcutaneous swellings were noted on extensor surfaces of both elbows and anterior shins.
Labs showed hemoglobin of 10 g/dL (normal 12-16), negative antinuclear antibody, rheumatoid factor, anti-CCP antibody, C-reactive protein of 0.23 mg/dL (normal 0-0.5), erythrocyte sedimentation rate of 37 mm/hr (normal 0-20), and uric acid of 10.6 mg/dL (normal 3-7). Bilateral hand X-rays (Figure 3) revealed severe periarticular osteopenia, severe joint space narrowing at radiocarpal, intercarpal, and carpometacarpal joints along with erosions in carpal bones and ulnar styloid processes. Musculoskeletal ultrasound showed double contour sign at multiple joints and tophaceous deposit over the right olecranon fossa. Nodular rash biopsied by dermatology was consistent with tophi on pathology. He was diagnosed with chronic tophaceous gout with nodulosis with overlap of seronegative rheumatoid arthritis (RA) given exam findings of symmetric wrist arthritis with severe reduced range of motion and X-ray findings suggestive of RA. He was started on urate-lowering therapy with allopurinol 100 mg daily, colchicine 0.6 mg BID for gout, and low-dose steroids (prednisone 10 mg daily) for RA. He had elevated liver enzymes at baseline and was also found to have latent tuberculosis, hence, additional DMARDs were not initiated at first. He was started on hydroxychloroquine and methotrexate eventually with tapering of steroids and clinical improvement in his symptoms along with exam findings. Allopurinol is being up titrated to target serum uric acid of less than 5.