Journal of Cytology
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Year : 2009  |  Volume : 26  |  Issue : 4  |  Page : 165-166
Tophi as an initial manifestation of gout

Department of Pathology, Kasturba Medical College, Mangalore, India

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Date of Web Publication5-Apr-2010

How to cite this article:
Gupta A, Rai S, Sinha R, Achar C. Tophi as an initial manifestation of gout. J Cytol 2009;26:165-6

How to cite this URL:
Gupta A, Rai S, Sinha R, Achar C. Tophi as an initial manifestation of gout. J Cytol [serial online] 2009 [cited 2022 Jan 17];26:165-6. Available from:


Gouty tophi presenting as periarticular masses are uncommon and often mistaken for a neoplasm. These nodules may not be recognized as tophi because the clinical diagnosis of gout in many instances is not straightforward. In such a setting, fine needle aspiration cytology (FNAC) of gouty tophi would facilitate the clinical diagnosis and treatment. We report one such case.

A 52-year-old male came to the surgical outpatient department with painful swellings near the elbow and ankle joint. On examination, two firm, immobile swellings were seen in the subcutaneous plane, on the posterior aspect of the left elbow joint and near the lateral malleolus of the left foot, measuring 5 × 4 cm and 4 × 3 cm. Clinically, a differential diagnosis of rheumatoid arthritis and neurofibroma was considered. FNAC was performed using a 21 gauge needle from both the lesions. The aspirate yielded chalky white amorphous material. The smears were stained with Papanicolaou and Leishman stain.

Microscopy revealed numerous needle-shaped crystals in stacks and dispersed singly with few scattered chronic inflammatory cells [Figure 1]a. Using polarized microscopy, the crystals were confirmed to be those of monosodium urate (MSU) [Figure 1]b. On further investigation, the serum uric acid levels were found to be elevated. A diagnosis of gouty tophi was established based on these findings.

Chronic tophaceous gout is characterized by macroscopic deposits of urate crystals associated with a central proteinaceous core, foreign body giant cells and macrophages. [1] These tophi are found in the periarticular and subcutaneous tissues, particularly around the olecranon process, knee joint, volar aspect of the forearm, Achilles tendon and helix of the ear. It is proposed that the occurrence of tophi at these sites is due to precipitation of uric acid crystals in cooler parts of the body. [2]

Measurement of serum uric acid is of limited help in the diagnosis of chronic tophaceous gout. The uric acid level in some patients with diabetes may be low or normal due to the uricosuric action of increased blood glucose levels. Lower levels of uric acid are also seen in alcoholics. [3],[4]

MSU crystals are often lost during histologic processing. However, they are preserved in cytologic smears that are alcohol fixed and hence polarization of fixed smears for confirmation of MSU is possible. [4]

The differential diagnosis of such a crystalline tophus would include tumoral calcinosis and tophaceous pseudogout. Both essentially represent soft tissue calcification and hence are picked up on radiology. [3],[4] Tumoral calcinosis and tophaceous pseudogout yield intensely basophilic, calcified material on FNAC in contrast to needle-like crystals observed in gouty tophi. [4] The deposits in tumoral calcinosis are amorphous and lack a crystalline structure. The calcium pyrophosphate dihydrate crystals of pseudogout are smaller, rhomboid or needle-shaped and show weakly positive birefringence as opposed to MSU crystals, which are longer and show strong negative birefringence. [4]

Thus, FNAC is valuable in confirming the nature of subcutaneous nodules. Whenever FNAC yields amorphous or granular material, gouty tophus should be considered in the differential diagnoses.

   References Top

1.Purohit MB, Purohit TM, Tandon RK. FNAC of gouty tophi-a case report. Indian J Pathol Microbiol 2006;49:42-3.  Back to cited text no. 1  [PUBMED]    
2.McCarty DJ. Gout without hyperuricemia. JAMA 1994;271:302-3.  Back to cited text no. 2  [PUBMED]    
3.Sah SP, Rani S, Mahto R. Fine needle aspiration of gouty tophi: a report of two cases. Acta Cytol 2002:46:784-5.  Back to cited text no. 3      
4.Rege J, Shet T, Naik L. Fine needle aspiration of tophi for crystal identification in problematic cases of gout. A report of two cases. Acta Cytol 2000;44:433-6.  Back to cited text no. 4  [PUBMED]    

Correspondence Address:
Astha Gupta
Assistant Professor, Department of Pathology, Kasturba Medical College, Light House Hill Road, Mangalore
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9371.62192

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  [Figure 1]

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