This 77-year-old man with a history of chronic arthritis developed multiple, tender, yellow nodules on his fingers. The clinical diagnosis of tophi was confirmed by histology and polaroscoppy showing needle-shaped birefringent urate crystals. When high uric acid has been present for a long time, deposits of uric acid salts may appear. Finding tophi during the first episode of gout is uncommon; they usually develop after 10 years in untreated patients who develop chronic gouty arthritis. While nodules typically appear along the helix of the ear, they can be found in other locations including the fingers and toes. The presence of tophi indicates the need for treatment with one of the long term uric acid lowering drugs (e.g. allopurinol).
Tophi can resemble rheumatoid nodules. Therefore, the finding of a rheumatoid nodule in a patient with a negative rheumatoid factor should prompt the clinician to consider gout in the differential diagnosis.
