Friday, January 20, 2012


Nikolaos Samaras, M.D., and Cecile Rossi, M.D.

 N Engl J Med 2012; 366:e6January 19, 2012

A 74-year-old woman with chronic renal failure was admitted for diarrhea and functional impairment. She was noted to have a tender, soft swelling of the medial and distal phalanx of the right index finger (Panel A). She had no history of joint inflammation or any recent use of diuretics but reported consuming a bottle of wine daily. Plain radiography showed substantial osteolysis of the distal phalanx and partial osteolysis of the medial phalanx (Panel B). Needle aspiration yielded a white viscous liquid, with numerous urate crystals identified on polarized light microscopy (Panel C). Abdominal computed tomography did not identify any uric acid stones. Slightly elevated levels of serum uric acid (386 μmol per liter) were attributed to chronic renal failure and untreated hypothyroidism. Bone destruction was attributed to tophaceous gout. Treatment with allopurinol and colchicine was initiated, and the patient was referred to an orthopedist who performed an arthrodesis of the remainder of the medial and distal phalanx. The patient was discharged without further complications.

Nikolaos Samaras, M.D.
Cecile Rossi, M.D.
Hôpitaux Universitaires de Genève, Geneva, Switzerland