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\begin{document}

\title{Multiple large joint swellings in an elderly alcoholic man}



\author[1]{Durga Neupane}%
\author[1]{Nimesh Lageju}%
\author[1]{Lokesh Jaiswal}%
\author[2]{Narendra Pandit}%
\author[1]{Asim Mahat}%
\author[3]{Saransh Ghimire}%
\author[4]{Upendra Pokhrel}%
\author[1]{Sefali Koirala}%
\affil[1]{BP Koirala Institute of Health Sciences}%
\affil[2]{Birat Medical College}%
\affil[3]{Kathmandu Medical College and Teaching Hospital}%
\affil[4]{Patan Academy of Health Sciences}%


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  \date{May 27, 2024}


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\textbf{Multiple large joint swellings in an elderly alcoholic man}

A 65-year-old male (BMI: 23 kg/m\textsuperscript{2}) with chronic
hypertension under amlodipine presented with chief complaints of
multiple joint swelling on bilateral hands and feet. The swelling
appeared 15 years back, and gradually increased over the years. The
patient had frequent pain from the swelling in the past, but instead of
seeking medical attention, he took over-the-counter painkillers. He has
no family history of such swellings but has a 35-year history of chronic
alcohol use, smokeless tobacco use, and cigarette smoking. On
examination, multiple large, firm, and immobile swellings were located
over the proximal and middle phalanges along with the
metacarpophalangeal joints of both hands (Figure 1). Similar swellings
were present over the metatarsophalangeal joints and ankle joints of
both feet (Figure 2). There was no ulceration over the swelling. On lab
evaluation, his uric acid level was 9.6 mg/dl (N: 2.5-7.8 mg/dl) with a
normal renal function test. Plain radiography of both hands and feet
revealed significant osteolysis of the involved joint. Needle aspiration
yielded white viscous fluid which showed numerous needle-shaped
birefringent crystals of monosodium urate on polarized light. The
patient was prescribed Allopurinol 100mg/day along with counseling on
lifestyle modifications.

An accumulation of monosodium urate crystals causes gout that most
frequently affects the first metatarsophalangeal joint. Risk factors
include increased age, alcohol use, osteoarthritis, purine-rich foods,
family or personal history of gout attacks, and medications such as
thiazide diuretics for hypertension.\textsuperscript{1}~Hyperuricemic
patients ([?] 6.8 mg/dl) can develop polyarticular tophaceous gout from
intermittent arthritis if untreated. Acute flares and tophi development
can be avoided by lowering blood urate levels with xanthine oxidase
inhibitors or uricosuric medications. A target serum uric acid level of
\textless{}6.0 mg/dl is desirable.\textsuperscript{2} Surgery is only
indicated for gout in situations of repeated attacks with deformities,
excruciating pain, infection, and joint damage.\textsuperscript{3}

\textbf{Conflict of interest:} None

\textbf{Consent:} Written informed consent was obtained from the patient
for reporting this case image.

\textbf{Ethical approval:} Not required

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Abdel-Khalek A, Tariq A, White JA, Cheema AR, Dhillon S, Tiesenga F.
  Atypical Presentation of Gout: A Case Report.~\emph{Cureus} .
  2023;15(3):e36707. Published 2023 Mar 26. doi:10.7759/cureus.36707
\item
  Aradoini N, Talbi S, Berrada K, Abourazzak FZ, Harzy T. Chronic
  tophaceous gout with unusual large tophi: case report.~\emph{Pan Afr
  Med J} . 2015;22:132. Published 2015 Oct 13.
  doi:10.11604/pamj.2015.22.132.6447
\item
  Falidas E, Rallis E, Bournia VK, Mathioulakis S, Pavlakis E, Villias
  C. Multiarticular chronic tophaceous gout with severe and multiple
  ulcerations: a case report.~\emph{J Med Case Rep} . 2011;5:397.
  Published 2011 Aug 19. doi:10.1186/1752-1947-5-397
\end{enumerate}

\textbf{Figure legends}

Figure 1: Multiple swellings of the proximal and middle phalanges along
with metacarpophalangeal joints of both hands

Figure 2: Multiple swellings involving 1\textsuperscript{st} and
5\textsuperscript{th} metatarsophalangeal joints and ankle joints of
both feet\selectlanguage{english}
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