APIK Journal of Internal Medicine

PICTORIAL CME
Year
: 2022  |  Volume : 10  |  Issue : 4  |  Page : 278--279

Tophaceous Gout and Martel's Sign: Manifestations of advanced gout


Swati Mahajan, Sujeet Raina, Vivek Sood 
 Department of Medicine, Dr. Rajendra Prasad Govt Medical College, Kangra, Himachal Pradesh, India

Correspondence Address:
Dr. Sujeet Raina
C-15, Type-V Quarters, Dr. RPGMC Campus, Tanda, Kangra - 176 001, Himachal Pradesh
India




How to cite this article:
Mahajan S, Raina S, Sood V. Tophaceous Gout and Martel's Sign: Manifestations of advanced gout.APIK J Int Med 2022;10:278-279


How to cite this URL:
Mahajan S, Raina S, Sood V. Tophaceous Gout and Martel's Sign: Manifestations of advanced gout. APIK J Int Med [serial online] 2022 [cited 2023 Feb 8 ];10:278-279
Available from: https://www.ajim.in/text.asp?2022/10/4/278/359441


Full Text



A 56-year-old male presented with multiple subcutaneous swellings over joints of hands, feet, elbows, and shin for the last 5 years. The swellings were increasing in size despite treatment and were painful and limiting range of motion. He was a known case of gout for the last 20 years and having recurrent episodes of gout flares. His treatment records revealed that he took analgesics initially and febuxostat 40 mg once a day for the last 10 years. Physical examination revealed bilateral subcutaneous swellings over the first metatarsal joint, olecranon, carpal, metacarpal, and metacarpophalangeal joints. Subcutaneous tophi were present and draining chalky, powdery discharge [Figure 1]a. On investigation, his serum uric acid level was 5.3 mg/dl. X-rays of feet revealed a punched-out lesion with overhanging margins at the first metatarsophalangeal joint involving the distal end of the first metatarsal and the proximal end of the phalanx. The X-ray finding is known as Martel's sign [Figure 1]b and [Figure 1]c. The patient was educated about the nature of his ailment and discharged on a low-purine diet and febuxostat 80 mg once a day.{Figure 1}

Gout is a clinical condition manifested by intermittent episodes of severely painful arthritis affecting preferentially lower-limb (foot, ankle, and knee) joints. First metatarsophalangeal joint involvement is characteristic (podagra).[1] Involvement of upper-limb (elbow, wrist, and hand) joints, polyarticular flares, tophaceous gout, joint deformities, and structural joint damage are features of advanced gout and indicate long-standing poorly controlled disease. Advanced disease may mimic rheumatoid arthritis.[2] The tophus is a cardinal sign due to chronic, foreign-body granulomatous inflammatory response to monosodium urate crystals. It consists of three main zones: a core of tightly packed monosodium urate crystals, a surrounding cellular corona zone, and an outer fibrovascular zone. Tophus develops after 5–10 years of chronic undertreated gout and prolonged elevated serum uric acid levels.[2] Martel's sign also known as “G sign” or “rat-bite erosion” is a well-defined, punched-out type lytic lesion with sclerotic margins and overhanging bony edges on X-rays. Martel's sign is eponymous with William Martel who gave this roentgenologic description. It is postulated that the outward displacement of the overhanging margin away from the bone contour reflects the enlarging tophus, which grows by multicentric deposition of urate crystals. During the progression, bone resorption at the interface with the tophus develops into a discrete erosion and, concomitantly, periosteal bone apposition at the outer aspect of the involved cortex causes the overhanging margin of the bone.[3] Other than gout, Martel's sign may rarely be observed in erosive osteoarthritis, destructive apatite arthropathy, and rheumatoid arthritis.[4]

The etiology of gout is very well understood, the diagnosis is easy, uric acid estimation is easily available and affordable, and the treatment is very effective and economical. However, gaps in quality of care persist either contributed by the poor compliance from the patient or treatment inertia at the treating clinician level. Advanced disease is a consequence of suboptimal care and incurs substantial costs in preserving quality of life. The principles of gouty arthritis treatment are long-term management with continuous urate-lowering therapy, prescribed at a dose which achieves monosodium urate crystal dissolution using a treat to target strategy. In this strategy, it is recommended to monitor serial uric acid levels and titrate urate-lowering therapy instead of fixed dose to achieve the target serum uric acid. The target serum urate in patients with gouty arthritis and tophaceous gout is <6 mg/dl and <5 mg/dl, respectively.[1],[2] This treatment strategy leads to suppression of gout flares, regression of tophi, and prevents joint damage.

Declaration of patient consent

The authors certify that we have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1FitzGerald JD, Dalbeth N, Mikuls T, Brignardello-Petersen R, Guyatt G, Abeles AM, et al. 2020 American College of rheumatology guideline for the management of gout. Arthritis Care Res (Hoboken) 2020;72:744-60.
2Dalbeth N, Gosling AL, Gaffo A, Abhishek A. Gout. Lancet 2021;397:1843-55.
3Martel W. The overhanging margin of bone: A roentgenologic manifestation of gout. Radiology 1968;91:755-6.
4Kundu AK, Chattopadhyay P, Biswas S. Martel's sign in chronic tophaceous gout. J Assoc Physicians India 2005;53:782.