Diagnosing an ulcerated gouty tophus

We present the case of a 44-year-old man with a complicated past medical history who presented with presumed sepsis secondary to pneumonia and severe joint pain secondary to gout. Despite an entirely negative infectious workup during his lengthy hospitalization, he developed ulcerated, draining wounds on his hands and feet that were also initially presumed to be infectious. The chalky substance draining from the wounds was eventually evaluated with potassium hydroxide under polarized microscopy and found to have the characteristic negative birefringence of sodium urate crystals. He was treated with steroids after an infectious etiology had been ruled out, and he improved clinically once his uric acid levels began to fall.