CASE REPORT Key words Biological therapy Gout Infliximab Metabolic disease

A Chiriac, A Chiriac, L Foia, T Pinteala, P Brzezinski
Τεράστιος τόφος σε ουρική αρθρίτιδα με καλή απόκριση στην ινφλιξιμάμπη Περίληψη στο τέλος του άρθρου Giant tophus in the course of gout, with a good response to infliximab A 76-year-old woman was referred for investigation of a large tumor on the left elbow that had first appeared more than 10 years earlier, with small firm yellow nodules on proximal and distal interphalangeal joints, which proved to be a manifestation of classic gout. Infliximab treatment resulted in marked clinical
more » ... clinical improvement. Gout is a metabolic disease caused by a disturbance in purine metabolism; crystals of monosodium urate are deposited in various tissues such as the joints, kidneys, and soft tissues, producing an inflammatory response. 1 Tophus (plural tophi) is a Latin word meaning stone and is the name given to deposits of monosodium urate crystals in people with longstanding high levels of uric acid in the blood. Tophi are most commonly seen in conjunction with the disease of gout, and most people with discernable tophi will have developed symptoms of gout. Tophi are most commonly found as hard nodules around the fingers, the tips of the elbows and the proximal joint of the big toe, but can affect any other part of the body. 2,3 CASE REPORT A 76-year-old woman with a past history of arterial hyper-tension, dyslipidemia and joint pain, affecting mainly the hands and knees, who was not receiving regular medication or medical attention, presented with a huge tumor localized on the left elbow (fig. 1). The tumor had appeared 10 years earlier, with a slow growth rate over the years, no pain, and no dysfunction of the left arm. The tumor was very well demarcated, covered by normal skin and firm with slight tenderness on palpation. She also displayed small painful soft whitish-yellow nodules affecting mainly the finger pads, with no sign of arthritis and no other complaints. She declined biopsy, but fine needle aspiration of the tumor for cytology confirmed the presence of uric acid crystals. A diagnosis of gout was made based on the clinical picture, the finding of hyperuricemia (18.6 mg/dL) and the cytology report. She was commenced on treatment with a combination of colchicine, NSAIDs, systemic glucocorticoids and xanthine oxidase inhibitors at the maximum appropriate doses, which produced no significant clinical or biochemical response; therefore, her condition was considered to be chronic tophaceous gout refractory to conventional therapy. Subsequently, a course of infliximab 3 mg/