A 49-year-old man was admitted to our clinic with pain, acute-onset swelling, and local erythema in his right big toe. He was under valsartan hydrochlorothiazide treatment for hypertension. The medical history was non-specific. He did have no constitutional symptoms such as morning stiffness, fatigue and fever. Physical examination revealed swelling, local erythema ( Figure 1a ) and pain on palpation of the right big toe. Serum C-reactive protein level was 14.6 mg/L (normal range: <10), and

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... acid level was 10.1 mg/dl (normal range: 3.5-7.2). Complete blood count, erythrocyte sedimentation rate, blood urea nitrogen and creatinine levels were within normal limits. While foot radiograph was unremarkable (Figure 1b) , ultrasonography showed sugar cluster appearance and effusion with increased power Doppler activity (Figure 1c, d) . Monosodium urate crystals were detected in synovial fluid aspiration, and the patient was diagnosed with gout. Oral colchicine 1 mg/d and diclofenac sodium 150 mg/d were commenced. Valsartan hydrochlorothiazide was changed to valsartan, and amlodipine was added for hypertension treatment. Uric acid poor diet and hydration were also recommended. Uric acid levels were 9.1 and 7.