Chronic tophaceous gout in a 72-year-old male presenting with fatal hypertensive hemorrhagic stroke: a case report

BACKGROUND: Chronic tophaceous gout is a well-recognized consequence of long-standing hyperuricemia. Although epidemiological evidence increasingly links hyperuricemia with elevated cerebrovascular risk, the co-occurrence of advanced tophaceous gout and fatal hemorrhagic stroke is infrequently reported, particularly from South Asian populations. CASE PRESENTATION: A 72-year-old Nepali male with a 15-year history of hypertension and a 12-year history of poorly controlled gouty arthritis presented following a fall with decreased consciousness. He was in hypertensive crisis (200/100 mmHg) with a Glasgow Coma Scale of 11/15 and left-sided hemiparesis. Physical examination incidentally revealed extensive subcutaneous tophi at bilateral elbows, left second metacarpophalangeal joint, bilateral first metatarsophalangeal joints, right Achilles tendon, and bilateral knees. Investigations showed hyperuricemia (serum uric acid 10.2 mg/dL), mildly elevated creatinine (peak 1.8 mg/dL), a normal coagulation profile, and absence of thrombocytopenia (platelets 172,000/μL). HbA1c was 5.1%, excluding diabetes. Neuroimaging confirmed a right thalamic hemorrhage with intraventricular extension. Despite ICU management, he deteriorated neurologically and was discharged against medical advice. He died five days after discharge. CONCLUSIONS: This fatal hemorrhagic stroke occurred in a patient with coexisting advanced tophaceous gout and long-standing hypertension. While the stroke was attributable to hypertensive crisis, the incidental finding of extensive tophi highlights the systemic burden of uncontrolled hyperuricemia. The case underscores the importance of sustained urate-lowering therapy and cardiovascular risk management in patients with gout, and the serious consequences of medication non-adherence.