HISTORY
Chief Complaint
Presenting for confirmatory diagnosis of the problem.
History of Present Illness
A 61-year-old normotensive gentleman presents with white, firm, lumpy nodules involving his bilateral hand. Prior treatment: allopurinol for a serum uric acid level of 9 mg/dl. His primary symptoms: joint pain and decreased mobility. Prior biopsy: none.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
One image was provided. The image clearly shows multiple yellow subcutaneous nodules with violaceous hues surrounding the metacarpal and metacarpal phalangeal joints of the bilateral hands. No size indicator is included in the photograph (see Figure 1).
INTERPRETATION OF IMAGES
Findings
The presented lesion is highly suspicious for tophi from gout.
RECOMMENDATIONS
Skin Care and Treatment Recommendations
The patient should be referred to rheumatology for a definitive diagnosis with needle aspiration of joint fluid to assess for the presence of monosodium urate crystals.
The patient is to be advised to limit dietary intake of animal protein (meat and seafood) and alcohol.
For acute pain, nonsteroidal anti-inflammatory drugs may be indicated.
RECOMMENDED FOLLOW-UP
Type of Visit
The patient is recommended to follow up with primary care and have a referral to rheumatology.
CLINICAL PEARL
Gout is a chronic metabolic disorder resulting from excessive deposition of monosodium urate crystals within the subcutaneous tissue. It was historically considered the disease of kings because of its correlation to a high-protein diet-and as such diets were expensive, only the wealthy were worthy of gouts' curse (Marson & Pasero, 2012). Gout most commonly presents with acute monoarticular arthritis, often of the first metatarsophalangeal joint (podagra). The involvement of finger joints presents in advanced disease (Kumar, Das, Savant, Mandal, & Hassan, 2012). The acute episode is characterized by dramatic joint pain and swelling, warmth, redness, and severe tenderness-this may often be confused with cellulitis. An advanced disease may be characterized by chronic synovitis and tophaceous deposits. Definitive diagnosis results from the analysis of joint space fluid for monosodium urate crystals. Lifestyle modification, including weight loss and reductions in protein and alcohol consumption, is often the first-line therapy. Therapeutic treatment includes nonsteroidal anti-inflammatory drugs, nontopical steroids, and colchicine. Of note, aspirin is contraindicated in gout because of its variable effect on renal uric acid excretion, which may lead to an acute exacerbation (Schumacher & Chen, 2012).
The standardized teledermatology reader report format is available for authors on the submissions Web site and outlined in Table 1.
REFERENCES