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A 77-year-old man presented with a 5-day history of painful swelling of his right elbow, which was also red, warm, and tender. When pressure was applied, a toothpastelike, white, chalky substance was easily expressible (Panel A). Four weeks earlier, palliative therapy with sorafenib had been started for metastatic renal-cell carcinoma. The patient reported that he was not taking any other medications and had no history of joint symptoms other than a compound fracture of the right elbow 30 years earlier. The serum creatinine and uric acid levels were slightly elevated (creatinine, 1.4 mg per deciliter [124 µmol per liter]; normal range, 0.6 to 1.3 [53 to 115]; and uric acid, 7.4 mg per deciliter [440 µmol per liter]; normal range, 3.4 to 7.0 [202 to 416]). Inspection of the entire body revealed one additional red, but painless, area of swelling over the right first distal interphalangeal joint (Panel B), which was associated with subepidermal, yellow–white material. We suspected an acute flare of previously asymptomatic, chronic tophaceous gout. Compensated polarized light microscopy of the expressed white, chalky substance revealed needle-shaped, negatively birefringent urate crystals (Panel C), confirming the diagnosis. The acute symptoms subsided rapidly with the use of allopurinol and prednisolone. No further flares have occurred.
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