An unusual ophthalmic presentation of inflammatory polyarticular gout

Gout affecting multiple organs and tissues is characterized by the deposition of tophi in subcutaneous tissues, joints, tendons, kidneys, myocardium, heart valves, auricular cartilage, spinal cord, and eyes. There are very few case reports of tophi involving eye in gout and usual locations are subconjunctiva, medial canthus, and cornea. 1, 2, 3 A 50-year-male, diabetic, with inflammatory polyarthritis was referred from Ophthalmology Department with recurrent nodular swellings over both knees (Fig. 1) and lateral malleoli (Fig. 2). He had undergone corneal patch graft (Fig. 3) for peripheral ulcerative keratitis and corneal perforation (Fig. 4). The patient was negative for IgM rheumatoid factor; ANA and c-ANCA, and p-ANCA. Elevated serum creatinine (1.7 mg/dl) with hematuria was reported. Radiograph of hands showed large cystic erosions of carpal bones on both sides (Fig. 5). Serum uric acid level of 7.3 mg/dl (normal range 3.6-7 mg/dl) was reported and synovial fluid examination showed intra-cellular needle shaped crystals suggestive of uric acid. The diagnosis was concluded as polyarticular gout based on the presence of nodules suggestive of atypical tophi, cystic erosions, and needle shaped crystals in synovial fluid.