Multiple large joint swellings in an elderly alcoholic manA 65-year-old male (BMI: 23 kg/m2) with chronic hypertension under amlodipine presented with chief complaints of multiple joint swelling on bilateral hands and feet. The swelling appeared 15 years back, and gradually increased over the years. The patient had frequent pain from the swelling in the past, but instead of seeking medical attention, he took over-the-counter painkillers. He has no family history of such swellings but has a 35-year history of chronic alcohol use, smokeless tobacco use, and cigarette smoking. On examination, multiple large, firm, and immobile swellings were located over the proximal and middle phalanges along with the metacarpophalangeal joints of both hands (Figure 1). Similar swellings were present over the metatarsophalangeal joints and ankle joints of both feet (Figure 2). There was no ulceration over the swelling. On lab evaluation, his uric acid level was 9.6 mg/dl (N: 2.5-7.8 mg/dl) with a normal renal function test. Plain radiography of both hands and feet revealed significant osteolysis of the involved joint. Needle aspiration yielded white viscous fluid which showed numerous needle-shaped birefringent crystals of monosodium urate on polarized light. The patient was prescribed Allopurinol 100mg/day along with counseling on lifestyle modifications.An accumulation of monosodium urate crystals causes gout that most frequently affects the first metatarsophalangeal joint. Risk factors include increased age, alcohol use, osteoarthritis, purine-rich foods, family or personal history of gout attacks, and medications such as thiazide diuretics for hypertension.1 Hyperuricemic patients (≥ 6.8 mg/dl) can develop polyarticular tophaceous gout from intermittent arthritis if untreated. Acute flares and tophi development can be avoided by lowering blood urate levels with xanthine oxidase inhibitors or uricosuric medications. A target serum uric acid level of <6.0 mg/dl is desirable.2 Surgery is only indicated for gout in situations of repeated attacks with deformities, excruciating pain, infection, and joint damage.3Conflict of interest: NoneConsent: Written informed consent was obtained from the patient for reporting this case image.Ethical approval: Not required