Tophaceous gout — SCE Rheumatology MCQ

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EasyCrystal arthropathiesTophaceous goutSCE Rheumatology

A 63-year-old man has chronic swelling and deformity of several proximal interphalangeal joints. Firm, chalky nodules are present over the helices of both ears. His serum urate concentration is 610 micromol/L, and hand radiographs show punched-out juxta-articular erosions with overhanging edges. What is the most likely diagnosis?

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Correct answer: A — Tophaceous gout

The diagnosis is **tophaceous gout**. The combination of auricular chalky nodules (tophi), marked hyperuricaemia and punched-out juxta-articular erosions with overhanging edges is characteristic of longstanding gout. Serum urate elevation alone is not diagnostic, but it strongly supports gout in this clinical and radiographic context. CPPD arthropathy more typically produces chondrocalcinosis and an osteoarthritis-like distribution. Rheumatoid arthritis causes marginal erosions and usually uniform joint-space loss rather than overhanging edges. Psoriatic arthritis may cause erosions with new bone formation, dactylitis or pencil-in-cup change. Erosive osteoarthritis predominantly affects DIP and PIP joints with central, gull-wing erosions and does not explain auricular tophi.

Reference: National Institute for Health and Care Excellence. NG219, Gout: diagnosis and management, section 1.1 Diagnosis and assessment. 2022. https://www.nice.org.uk/guidance/ng219/chapter/Recommendations