Tofusi with gout

Interstitial foci of densification in the form of knobby nodes of various sizes with deposition of crystallized uric acid and its salts in rheumatology are defined as tophi in gout. They are one of the clinical manifestations of chronically occurring gout and occur at any stage of the disease with a frequency of up to 25%.

The pathology was assigned to the ICD code 10 - M10, class XIII (diseases of the musculoskeletal system and connective tissue).

Causes of tofus in gout

The pathogenesis of tofus, like the gout itself, has a systemic exchange character and is associated with hyperuricemia, an excessive content in the blood of the nitrogenous bases of uric acid that is constantly formed during metabolism. When the levels of free uric acid in the blood plasma are too long (at a rate of 1-1.2 mg / dl) for a long time, and the acidity (pH) of the blood is also increased, the formation of crystals occurs not only in the synovial fluid of the joints, articular bags ) and the surrounding joints of the fibrillar tissues of the cartilage and tendons, but also in other tissues, primarily the dermal ones.

That is, the key causes of tofus in gout are the local accumulation of the products of the abnormal altered cycle of uric acid in the body brought by the bloodstream. The smallest insoluble crystals of uric acid and sodium monoaurate by infiltration or diffusion (finally not yet clarified) fall into the intercellular space of peripheral tissues and disrupt their structure in separate areas where bulk pathological clusters appear over time. The mechanism of tofus formation resembles epithelioid cell granulomatosis, since in addition to concentrated urate crystals in tofus there is granulomatous tissue with giant multinucleate cells and dead macrophages.

Tofusy with gout are of different sizes and different to the touch (most often tight and dense enough); have clear boundaries, since the undamaged tissues are separated by a layer of fibrous fibers. They have the appearance of protruding "cones" above the surface of the skin. Over time, their calcification (calcification) or heterotopic ossification (ossification) can be noted.

The most characteristic places for the appearance of tophi are the fingers and toes, feet, elbows (near the elbow), the knees, the ears - that is, the colder parts of the body where there are no large blood vessels, and the temperature drops towards the lower contribute to the process of precipitation of the crystals. However, tofus can occur in bone tissues, and in the tissues of internal organs (most often the kidneys).

[1], [2], [3], [4]

Symptoms of tophi in gout

Patients with gout may not notice the first signs of the appearance of the tofus form of the disease, since at the initial stage the cluster of crystals can pass in the deeper layers of the subcutaneous tissue. If you look closely, you can see whitish spots - when tofus grows closer to the surface of the skin, which gradually becomes more pale in this place.

Obvious symptoms of tofus in gout are expressed in small, medium or rather large yellowish or white nodes under the skin - on the fingers, toes, flexion part of the elbows, about a heel (in the Achilles tendon zone) or the ankles and around the outer edge of the ear. In most clinical cases, tofus do not cause pain, or these feelings are minor. But as the size increases, the tofus begin to exert mechanical pressure, which makes the pain worse.

Tofusy can break through the epithelium and the subepithelial layer of the skin, and a fistula (fistula) is formed. The contents of tofus pasty or granular consistency outward, and in place of the fistula on the skin remains ulcer.

The liquid contents of tofusa speaks about the inflammatory process, however, as rheumatologists note, the inflammation inside the unopened tofus does not usually develop.

Tofuses with gout, especially large ones, cause complications, deforming the joints. And the most serious consequences of the deposition of uric acid crystals in tissues are destruction of cartilage and erosive defects of bones.

Diagnosis of tofus in gout

Diagnosis of tofus begins with a gout with their visual examination by a rheumatologist. Then you need to pass the tests:

• clinical blood test;
• biochemical analysis of blood with the establishment of uric acid level;
• daily urine analysis.

Instrumental diagnostics is performed using X-rays or, if necessary, ultrasound.

Gouty tophi can be mistaken for tumor calcification in basal cell carcinoma or sarcoidosis, pseudogout (with the crystallization of calcium pyrophosphate), spondyloarthritis or ostearthrosis, as well as Kaposi's sarcoma, neurofibrosarcoma, dermoid cyst or - for localization in the auricle - for nodal hododermatitis of the cartilaginous curl ear. Therefore, differential diagnosis should be carried out. The final diagnosis of gouty tophi is established by the detection of crystallized monosodium urates in tofus or nearby joints, for which purpose fine needle aspiration is conducted and the sample is studied using polarization microscopy to see crystals of uric acid or its salts. And to exclude tumors, the doctor prescribes a biopsy with histology.

[5], [6]

Tofus treatment for gout

How to remove tophi at gout? It is necessary to have a long but effective medication for tofus with gout with uricosuric drugs, which reduce the uric acid content in the blood.

Reduce the size of tofus help drugs that affect the cycle of uric acid - due to more intensive removal of it through the kidneys:

• Benziodarone is prescribed in a daily dose of 100 to 300 mg.
• Benzbromarone (an analog of Benziodarone, differs by the presence of bromine in the composition); is taken once a day, the minimum dose is 0.05 g, the maximum dose is 2 g.
• Probenecid (other trade names - Benedom, Santuril), is prescribed by 0.25-0.5 g twice daily.
• Etamide (Etabenecid) - a remedy similar to Probenecid. The standard daily dose is 1-1.4 g (in four divided doses); It is accepted by courses for 10 days with weekly breaks.
• Sulfinpirazone (Sulfazon, Anturan, Enturan) - should take one tablet (0.1 g) three times a day (after eating, squeezed milk).

But the action of the drug Allopurinol (Alloprim, Allogexal, Ziloprim, Zilorik, Milurit, Purinol) is based on the maximum decrease in the participation in the metabolism of uric acid enzyme xanthine oxidase. As a result, the synthesis of uric acid decreases and, accordingly, its entry into the blood. The usual dose is 1-3 g per day (the individual dosage is determined by the doctor according to the results of the blood test). The use of this drug requires an increase in the daily volume of fluid consumed to two liters.

Experts consider expeditious treatment of gouty tophi, if tofusi: destroy joints or negatively affect the function of tendons; threaten to cause skin necrosis and ulcers; accompanied by suppuration; squeezing nerves and hurting; have an unsightly appearance. Surgical intervention is also carried out in those cases when the total volume of urate in the body can be reduced by removing easily accessible tofuses of large sizes.

Alternative treatment of tofus with gout is to lubricate the cones with an alcohol solution of iodine, in which it is recommended to add several powdered acetylsalicylic acid tablets. Can help warm baths with English salt (tablespoon per glass of water).

You can also try and treat herbs: take in the water infusions of medicinal plants such as nettle, black elderberry (flower), stigmas corn, cranberries (leaves), etc.

Among the remedies recommended for tophus homeopathy, there is a drug with Ledum Palustre and Lycopodium clavatum with clavulum.

Preventive maintenance is the key to reducing the risk of gouty cones. And to reduce the level of uric acid there is a special diet, for more details see - Diet for gout. Be sure to drink enough clean water (at least 5-6 glasses a day).

Prognosis in the absence of treatment: tofus are a source of uric acid, which can return to the bloodstream, which will increase its concentration and increase the chances of further attacks of gouty rheumatism. In addition, tofusi with gout can destroy the skin, tendons, ligaments and skeletal structures, and this ultimately limits the ability of the musculoskeletal system and leads to disability.