a 59-year - old male presented with painful swelling of his hands and knees and subjective fever over the preceding few days . the pain affected joints of hands and knees and was aggravated by a range of motion . numerous tender subcutaneous nodules were noted on examination of his hands ( shown in the fig . 1 ) and prepatellar areas . uric acid was elevated to 9.7 mg / dl , and creatinine to 1.5 mg / dl . gouty tophi presenting as multiple large periarticular masses could be mistaken for rheumatoid nodules , neoplasm ( 1 , 2 ) , neurofibromata ( 3 ) , or infection . aspiration of synovial fluid from inflamed joints or examination of whitish material expressed though breaks in the skin usually assists with a diagnosis of gout ( 1 ) . however , in cases as shown here , the appearance of the tophi is pathognomonic for gout . aspiration may still be needed for exclusion of concomitant infection and  de - bulking of inflamed joints to expedite healing .
gouty tophi presenting as multiple large periarticular masses could be mistaken for rheumatoid nodules , neoplasm , neurofibroma , or infection . 
 aspiration of synovial fluid from inflamed joints or examination of whitish material expressed though breaks in skin usually assists with the diagnosis of gout .