A Missed Opportunity: Tophaceous Gout

      The following case represents a missed opportunity to diagnosis chronic tophaceous gout. Several features of one patient's case belied the original diagnosis. A 70-year-old Filipino man presented to the clinic, complaining of subacute worsening of chronic hand pain. Two weeks prior, he experienced increasing pain and swelling of the metacarpophalangeal joints and both wrists. Over the past several years, he had similar episodes, each lasting 2-3 weeks; shorter when he received oral nonsteroidal anti-inflammatory drugs or prednisone. Between these periods, minimal joint swelling and stiffness remained. Nevertheless, over time, he noted progressive deformity of his metacarpophalangeal joints. In addition, he reported occasional pain during use of the left shoulder and both knees. He denied fever, chills, rash, or neurologic problems. He had a history of hypertension, chronic renal insufficiency, and remote heavy alcohol use. His only medications were naproxen and acetaminophen.
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