Gouty Tophi in Developed Countries: Uncovering Underlying Brain Diseases

A 56-year-old man, accompanied by city hall staff, visited our neurorehabilitation clinic. Despite hyperuricemia being diagnosed several years ago, he refused treatment. He had no history of hypertension and antihypertensive drug use. He developed painful joint tophi around the age of 51, which were managed with over-the-counter painkillers. At age 54, a knee tophus was removed, histologically confirming gouty tophi. Subsequently, he lost his chef's job, and his lifestyle deteriorated. Gouty tophi were observed in the right ear, knuckles, elbows, and ankles, with some ulceration. Blood tests showed anemia and hyperuricemia (10.1 mg/dL: reference 3.6-7.0 mg/dL). Chest-abdominal CT demonstrated calcification of the aorta. Brain MRI revealed an old putaminal hemorrhage and numerous microbleeds. Dementia (Clinical Dementia Rating: 1) was diagnosed based on neuropsychological testing. Public services and social assistance were arranged for him. This case is hypothesis-generating. In settings with adequate healthcare access, the presentation of severe, uncontrolled gouty tophi with poor engagement should prompt a selective, stepwise evaluation-beginning with cognitive screening and proceeding to neurologic assessment if indicated; routine preventive brain imaging is not recommended. The presence of lobar and deep microbleeds should be interpreted within the context of standardized diagnostic criteria and lesion distribution patterns to inform differential diagnosis.