LAUSR

A 58-year-old man with onset of gout 8 years ago was admitted due to poor clinical conditions. He was treated with allopurinol 300 mg/day, but the dosage was not adjusted to the level of persistent uricemia (11 mg/dl). In this scenario, our patient experienced recurrent polyarticular gouty attacks despite being adherent to the prescribed therapy. Gigantic tophi (Fig. 1a, b), walking difficulties and feet ulcers due to spontaneous evacuation of a tophus were clinically evident. Hands and feet X-ray showed multiple destructive bone erosions due to large tophaceous depositions (Fig. 1c, d). Musculoskeletal ultrasound (MSUS) identified the presence of double contour sign (DCS, arrow) in the metacarpophalangeal joint and active synovitis in the joints of hands and feet (Fig. 1e, f, *). Monosodium urate (MSU) crystals were detected in the knee fluid as well as in the ulcerated tophaceous deposits. According to EULAR recommendations, colchicine 1 mg/day, NSAIDs, omeprazole 20 mg/day and urate lowering therapy with allopurinol adjusted to uric acid levels (600 mg/ day) were prescribed. Knee fluid aspiration and intra-articular long-acting corticosteroid injection (Betamethasone) were performed [1]. Other laboratory analyses, renal/ cardiac function and systemic blood pressure were normal. No kidney stones were detected. In the following two months, uric acid levels were significantly lowered (5.7 mg/dl). Febuxostat was identified as a potential future alternative therapy in case high dosage intolerance/side effects to allopurinol would appear. Follow-up visits in the next 18 months did not ident i fy new joint / periarticular attacks. The ulcers showed a trend toward resolution but did not reach complete healing. Less walking difficulties were recorded mainly due to knee joint pain reduction.