Decoding skin deposits: a rare case of miliarial gout

Gout, metabolic disorder characterized by hyperuricemia and deposition of monosodium urate crystals in joints, soft tissue, and peri articular tissues causing recurrent arthritis. Here, we present a case of disseminated gout with distinctive cutaneous lesions and systemic comorbidities. A 50-year-old chronic alcoholic male presented with multiple white to yellowish papules with extrusion of chalky white materials all over body with soft tissue swelling over right elbow and distal joints for 3 years with joint pain. On clinical examination, multiple yellowish-white, non-tender, hard papules and nodules on an erythematous base present along the forearms, shoulders, and upper back with discharge of white chalk-like material. There were multiple soft tissue swellings over the right elbow and interphalangeal joints of hands and feet with flexion deformity and limitation of movement. Diffuse grain like aggregations of whitish gritty substance noted over the palms and soles. Musculoskeletal examination revealed swelling, tenderness, and warmth over both ankles, elbows, metatarsophalangeal (MTP), and metacarpophalangeal (MCP) joints. Other systemic and neurological examinations were unremarkable. Investigations showed increased uric acid level. With X-ray and histopathological examination, diagnosis of tophaceous gout (miliary) was made and managed accordingly. Various forms of chronic tophaceous gout have been described: classic periarticular subcutaneous tophi, disseminated intradermal tophi, ulcerative form, and gouty panniculitis. Miliarial gout is an extremely rare form of tophaceous gout that manifests as "milia-like" widely distributed papules containing white to cream-colored material on an erythematous base.