From suspected joint tuberculosis to gouty arthritis: a diagnostic journey

Gout is a metabolic disorder characterized by hyperuricemia, leading to the deposition of monosodium urate crystals in joints and soft tissues. It commonly affects the first metatarso-phalangeal (MTP) joint, but atypical presentations can pose significant diagnostic challenges. In this report, we describe a rare case of gouty arthritis affecting the proximal interphalangeal (PIP) joint of the second toe, which was initially suspected to be a case of joint tuberculosis. A 38-year-old male presented with a painful swelling over the second toe for two months, with imaging and laboratory findings suggesting an infectious etiology. Despite clinical suspicion of tuberculosis, histopathological examination of the lesion confirmed the presence of amorphous eosinophilic material with chronic inflammatory infiltrate and giant cell reaction, indicative of gout. Subsequent serum uric acid evaluation revealed hyperuricemia, leading to a definitive diagnosis. The patient underwent surgical evacuation of the tophaceous deposits followed by medical management with colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and allopurinol. Postoperative follow-up demonstrated complete resolution of symptoms with no recurrence. Aim of the study: This case report aims to highlight the diagnostic challenges of atypical gout presentations, particularly when mimicking infectious conditions such as tuberculosis. It underscores the importance of maintaining a broad differential diagnosis, utilizing histopathology for confirmation, and considering gout even in uncommon anatomical locations.