Crab-like hands as an unusual presentation of a rheumatic disease

Tophaceous gout can present with aggressive tophi causing destruction of the soft tissues, joints, and bones (1,2). A 68-year-old male presented with intense pain in the upper and lower limbs persisting for several weeks. He reported no limb weakness or history of trauma. The patient's medical history included severe tophaceous gout, chronic renal insufficiency, and heart failure. The patient had a poor social condition. On physical examination, he exhibited poor hygiene, cachexia, and dehydration. Active drainage of gout tophi was observed. The normal anatomy of the hand was lost due to joint destruction and fusion of the interdigital spaces (see figure 1 - panel A). Also, a giant tophus can be observed in the first finger of the left hand as well. The patient displayed limited range of motion in the wrists, fingers, and elbows, with hindered mobilization of knees, ankles, and feet due to pain. Subsequent blood tests revealed anemia, leucocytosis with neutrophilia, serum creatinine of 2.68 mg/dL, blood urea nitrogen of 147 mg/dL, and C-reactive protein (CRP) of 15.4 mg/dL. X-rays of the hands (figure 2), elbows, and feet revealed multiple "punched-out" erosions with sclerotic margins, indicative of massive bone and joint destruction. Appropriate wound dressing was provided, and the patient was initiated on antibiotics, corticosteroids, and urate-lowering therapy. While CRP and anemia showed slight improvement, patient began to refuse nutrition, his renal function declined, and he died 10 days after admission. To the best of our knowledge, this represents an extremely rare case of joint fusion resulting from tophaceous gout, attributed to untreated aggressive disease and challenging social circumstances. In such instances, a multidisciplinary approach that includes healthcare professionals, social workers, and mental health experts is essential.