An Overview of Tophi in Gout

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Tophi  (singular: tophus) are chunky deposits of uric acid crystals—also known as monosodium urate—that accumulate in and around joints of people with advanced gout. Although they are usually painless, they can erode bone and joints and destroy cartilage, leading to chronic inflammation. That inflammation can be very painful. The skin that lies over tophi (Latin: "stone"), which typically appear bulbous and swollen, often becomes taut and eventually ulcerates, releasing a soft, white material made of hardened uric acid.

Learn more: Symptoms of Gout

Symptoms

There are three stages of gout, and tophi generally start to develop in the joints and tissues in the advanced chronic tophaceous stage. This occurs an average of 11.6 years after your first attack of gout. and is characteristic of gout that has gone untreated for long periods of time. The formation of these mineralized masses can also lead to chronic arthritis and joint deformity.

Tophi can occur in cartilage, synovial membranes, joint cartilage, tendons that connect joints to muscles, and soft tissues. While they're usually found as hard nodules on fingers, the tips of elbows, and around a big toe, they can occur in many other body parts including:

  • Wrists
  • Ears
  • Knees
  • Forearms
  • Achilles tendons
  • Renal pyramid of the kidneys
  • Heart valves
  • Sclera (white outer layer of the eyeball)

Tophi develop in 12-35% of gout patients. Initially, they may not cause pain or limit function of joints. But if they become larger, they can cause joint instability, limit your range of motion, and erode bone at the joint site.

Causes

Tophi form as a result of high levels of uric acid in the blood, a condition that's known as hyperuricemia. Left untreated, gout can cause kidney stones and the deterioration of of kidney function)

Diagnosis

The gnarled, twisted appearance of tophi on hands or other parts of the body is typical. Lab tests can confirm a diagnosis: Magnetic resonance imaging (MRI) or computed tomography (CT) scans evaluate larger tophi as well as the extent of bone and cartilage damage to surrounding joints. A CT scan will yield the most detailed and precise images. Tophi can also be aspirated, and the tophaceous material is expressed and analyzed under a microscope to confirm a diagnosis of chronic tophaceous gout.

Treatment

Treating tophi is often part of a comprehensive gout treatment plan, and includes uric acid-reducing medications and lifestyle changes such as weight management and a diet low in foods that contain purines, such as veal, mussels, tuna, bacon, and beer.

Small tophi that don't cause any pain or limit your movement may not have to be removed — your doctor may prescribe drugs or change your diet to shrink them. For larger tophi, surgical excision may be the best course of action to prevent furter damage or the loss of range of motion in your joint.

Several drugs have been found effective at lowering levels of uric acid in the blood to 5 milligrams/deciliters (mg/dL), which is the point at which tophi will dissolve. These include Aloprim (allopurinol), Uloric (febuxostat), Krystexxa (pegloticase), and Benemid (probenecid).

With treatment, tophi can be dissolved and will completely disappear over time.

A Word From Verywell

If you have gout, it is important to monitor your uric acid levels regularly—even during periods when you're asymptomatic and between attacks. Understandably, it's easy to stop paying attention when the gout is dormant and you're pain-free. If you manage gout properly at all times, you stand a better chance of successful longterm treatment. You can head off a decreased quality of life that people with tophi often experience because their gout has been untreated for too long. The good news? With treatment tophi can be dissolved and completely disappear over time.

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Article Sources

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  1. Chhana A, Dalbeth N. The gouty tophus: a review. Curr Rheumatol Rep. 2015;17(3):19. doi:10.1007/s11926-014-0492-x

  2. Ragab G, Elshahaly M, Bardin T. Gout: An old disease in new perspective - A reviewJ Adv Res. 2017;8(5):495–511. doi:10.1016/j.jare.2017.04.008

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