A Case of Tophaceous Gout Complicated by Intraosseous Tophi and Falciparum Malaria: Double Trouble

colchicine, oral steroids, and febuxostat in various combinations for the last 15 years.Despite the various courses of medications, his disease continued to progress, leading to multiple deformities due to suboptimal therapy.10 days prior to admission, the patient developed a high-grade fever with diffuse swelling of the right lower limb.On examination, the patient looked unwell and was febrile (temperature 39.8°C) with a pulse rate of 114/minute and blood pressure of 110/70 mm Hg.On musculoskeletal examination, there were multiple, asymmetric, firm, skin-colored to yellowish nodules present in the hands, wrists, feet, knees, and subcutaneous tissues.Some of the ulcerated nodules discharged chalky material, with fixed deformities in multiple joints (Fig. 1).His blood investigations revealed anemia, hemoglobin 8.8 gm/dL (normal range, 12-15 gm/dL), polymorphonuclear IntroductIonGout is a metabolic disorder marked by recurrent painful inflammation of the joints due to the deposition of monosodium urate (MSU) crystals in tissues because of excessive uric acid accumulation.Gout frequently manifests as asymmetrical joint disease and can result in acute or chronic inflammatory arthritis.Chronic gout is distinguished by the accumulation of MSU crystals as a tophus (Latin: "stone") in various connective tissues, which is pathognomonic for gout.Tophaceous gout usually results from chronic disequilibrium between uric acid production and excretion.In chronic tophaceous gout and refractory chronic gout (RCG), the disease can lead to multiple tophi formation, usually in the joints, subcutaneous tissue, and nephrolithiasis.However, intraosseous tophi are rare in gout.There have been few reports linking falciparum malaria and hyperuricemia.[1][2][3] However, we highlight the first case of intraosseous gouty tophi and falciparum malaria, successfully treated with antimalarial drugs and allopurinol, a urate-lowering therapy.There is limited information about this dual association between intraosseous gout and falciparum malaria.Therefore, we feel it is important to report this rare case.In addition to our unique case, we present a brief literature review on critical aspects of tophaceous gout, the clinical significance of intraosseous tophi, and the association of falciparum malaria and gout along with their management. case descrIptIonA man in his early 35-year-old male presented to the emergency department at a Tertiary Institute in northeastern India with a history of recurrent, multiple ulcerated, painful nodules over bilateral hands, feet, elbows, and knees for the last 15 years.The lesions began as small, painless nodules in the great toe, which eventually progressed to involve multiple joints with intermittent acute flare-ups.Some of the nodules became ulcerated and discharged white, chalky material.The patient had no known history of diabetes mellitus, hypertension, or hematological disorders.He was not on any immunosuppressive medications, and there was no family history of gout.He was treated with nonsteroidal anti-inflammatory drugs, allopurinol,