A 34-year-old man presented with severe pain in multiple joints. He was diagnosed with gout 4 years ago; however, he had not been administered any medication for this condition. He was obese (body mass index, 36.3 m /kg), and laboratory tests showed increased levels of uric acid (11.4 mg/dL). Physical examination revealed severe edema and pain in the joints with tophi in the following sites: the right first metatarsophalangeal, both lateral malleoli, distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints and ears ( ). Following administration of prednisolone and colchicine, the pain improved. Despite the need for continuous treatment, he did not return to our clinic until a year later. He revisited our clinic with multiple painful and itchy yellowish papules on the anterior and posterior pretibial areas ( ). Before visiting our clinic, he had been diagnosed with acne or folliculitis and had been prescribed a topical steroid ointment at a local clinic; however, the pain had not alleviated. We performed a dual-energy computed tomography (DECT) and skin biopsy. The DECT showed increasing signals in the left anterior and right posterior pretibial areas, suggestive of tophi ( ). The skin-biopsy examination showed dispersed birefringence with fine needle shaped crystals and negative birefringence ( ). Based on these findings, the patient was diagnosed with miliarial gout with classical tophi.
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机译：一名34岁的男子在多个关节处出现严重疼痛。 4年前，他被诊断出痛风。但是，他没有为此病接受任何药物治疗。他肥胖（体重指数36.3 m / kg），实验室检查显示尿酸水平升高（11.4 mg / dL）。体格检查发现以下部位的痛风石伴关节出现严重水肿和疼痛：右侧第一meta趾趾，外侧踝，趾间远端，趾间近端和掌指关节和耳朵（）。泼尼松龙和秋水仙碱给药后，疼痛得到改善。尽管需要持续治疗，但直到一年后他才回到我们的诊所。他重新审视了我们的诊所，在胫骨前部和后部区域出现多个疼痛且发痒的淡黄色丘疹（）。在去我们的诊所之前，他被诊断出患有痤疮或毛囊炎，并在当地一家诊所开了局部类固醇药膏。但是，疼痛并没有减轻。我们进行了双能计算机断层扫描（DECT）和皮肤活检。 DECT在左前和右后胫骨区显示出增加的信号，提示是tophi（）。皮肤活检显示双折射散在，针状晶体细，双折射为负。基于这些发现，该患者被诊断出患有古典痛风石的粟粒性痛风。
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