Disseminated Cutaneous Tophaceous Gout in a Man With Advanced HIV Disease

Cutaneous tophi typically develop at periarticular sites in patients with longstanding gout.Widespread dermal deposition of monosodium urate beyond these sites is uncommon and is not recognized as a manifestation of human immunodeficiency virus (HIV) infection.We report a 54-year-old man with advanced HIV disease who presented with a ten-year history of progressively enlarging nodules on both lower limbs.HIV had been diagnosed in 2019, and he had been virologically suppressed on tenofovir disoproxil fumarate, lamivudine, and dolutegravir since 2020, although his CD4 count remained 34 cells/µL.The lesions were asymptomatic and had not previously been investigated.Examination showed numerous firm, hyperpigmented papules and nodules across both lower limbs together with bilateral olecranon tophi.Serum urate was 0.61 mmol/L, renal function was mildly reduced, and body mass index was 41 kg/m².Punch biopsy demonstrated dermal deposits of amorphous, feathery eosinophilic material bordered by a granulomatous infiltrate, and stains for mycobacteria and fungi were negative.No tissue cultures were obtained; disseminated cutaneous tophaceous gout was diagnosed by clinicopathologic correlation rather than crystal identification.Allopurinol was restarted with dose escalation and colchicine prophylaxis.At six months, the serum urate had fallen to 0.40 mmol/L, within the laboratory reference range but above the target for tophaceous gout, and the tophi had not regressed.This case shows how asymptomatic skin disease can go uninvestigated for years in a patient with a demanding chronic illness.We report the two conditions as coexisting and do not suggest that HIV caused the cutaneous tophi.