Uncommon Manifestations of Gout in Advanced CKD: Miliarial Gout and Martel’s Sign

A 25-year-old male diagnosed at 19 years of age with atypical hemolytic uremic syndrome (aHUS) was treated with plasma exchange, showed a partial response, but relapsed in 2018, progressing to advanced kidney failure. In June 2021, he presented with painful swelling over the medial left great toe. Radiography revealed soft tissue and bony changes [Figure 1a], and biopsy showed stratified squamous epithelium with subepithelial amorphous eosinophilic deposits rimmed by palisaded histiocytes, lymphocytes, and multinucleated giant cells. Although monosodium urate crystals dissolve in formalin (alcohol preservation preferred), findings confirmed chronic tophaceous gout. Serum uric acid was 13 mg/dL; febuxostat was started at 80 mg daily to lower uric acid below 6 mg/dL, and then later switched to allopurinol (50 mg daily escalated slowly to 300 mg daily). Despite treatment, serum uric acid levels remained above 10 mg/dL. Over 3 years, multiple tophaceous swellings developed on the elbows, hands, and feet with recurrent flares, and were managed intermittently with steroids. In September 2025, he presented with severe left great toe pain [Figure 1b] and numerous yellow white papules on palms and finger pads [Figure 1c]. Radiograph showed classic “punched-out” erosions with sclerotic margins and overhanging edges progressing to a large geographic lytic lesion at the first metatarsophalangeal joint¹ (Martel’s sign, or “G-sign”/”rat-bite” erosion), typical of chronic tophaceous gout. Differential diagnoses for palmar papules included gout, calcinosis cutis, chondrocalcinosis, pyogenic pustules, and oxalosis. In this case, biopsy confirmation of gout elsewhere and extensive tophi supported the finger pad and palmar “miliarial gout”² diagnosis. High-quality evidence for gout treatment is lacking, as advanced CKD patients are often excluded from urate-lowering therapy (ULT) trials. Guidelines differ on allopurinol dosing in gout patients with CKD:European Alliance of Associations for Rheumatology limits doses based on creatinine clearance, while ACR supports gradual escalation to maximum doses.³ Despite consistent ULT, gout progressed as the CKD progressed, highlighting treatment challenges and the need for further research to improve management.

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Figure 1:

(a) Radiograph showing well-defined “punched-out” erosions (orange arrow) with sclerotic margins and overhanging edges (b) progressing to a large geographic lytic lesion (orange arrow) at the first metatarsophalangeal joint - Martel’s sign. (c) Finger pad tophi and palmar tophi - “miliarial gout” (yellow arrows).

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