8/10/2019 Rheumatology 2006 Khanna 1095

1/1

altered in phenotype and lineage flexibility. Ann Rheum Dis

2000;59:2838.

18. Decker P, Singh-Jasuja H, Haager S, Ko tter I, Rammensee HG.

Nucleosome, the main autoantigen in systemic lupus erythematosus,

induces direct dendritic cell activation via a MyD88-independent

pathway: consequences on inflammation. J Immunol 2005;174:

332634.

19. Hooks JJ, Moutsopoulos HM, Geis SA, Stahl NI, Decker JL,

Notkins AL. Immune interferon in the circulation of patients with

autoimmune disease. N Engl J Med 1979;301:58.

doi:10.1093/rheumatology/kei141Clinical VignetteAn unusual presentation of polyarticular tophaceous gout

A 60-yr-old man presented with a 15-yr history of episodic,inflammatory polyarthritis with subcutaneous tophi over the leftelbow. He was diagnosed with polyarticular gout after goutycrystals were demonstrated from joint fluid. He was treated withcolchicine and allopurinol. He was seen after 1 month when hecomplained of the spontaneous development of multiple intra-dermal bullae over the lateral and medial aspects of the feet,heels and in the skin overlying the tendoachillis (Fig. 1; see alsosupplementary Figs 2 and 3 available at Rheumatology Online).The deposits were mildly painful and yellowish white without signsof inflammation. Aspiration from the deposits revealed chalky

fluid containing needle-shaped crystals. The patient was diagnosedas tophaceous gout with bullous tophi.

Tophi are usually firm nodular subcutaneous deposits, but mayrarely be intradermal pustules or plaques. Tophi presenting assuperficial bullae have only once been reported in the Englishliterature [1]. That case was precipitated by a burn causing localtissue injury in one patient. In our patient, the tophi presentedas intradermal bullae only on the margins of the sole and heel.Since acute or repetitive trauma is a known precipitating factor ofgouty attacks, it could be postulated that imperceptible traumato the feet precipitated the tophaceous bullae. The skin deposits

did not invite the inflammatory response, possibly because thepatient was on colchicine.

The authors have declared no conflicts of interest.

Supplementary data

Supplementary figures are available at Rheumatology Online.

D. KHANNA, A. SHRIVASTAVA

Department of Clinical Immunology and Rheumatology,KLES Hospital and Medical Research Centre, Belgaum,Karnataka, India

Correspondence to: A. Shrivastava, Department ofClinical Immunology and Rheumatology, KLES Hospital andMedical Research Centre, Belgaum, Karnataka, India.E-mail: arun453@yahoo.com

References

1. Schumacher HR. Bullous tophi in gout. Ann Rheum Dis 1977;36:913.

FIG. 1. Feet showing bullous tophi.

CD86 over-expression by lupus dendritic cells 1095