Peer Reviewed

What’s Your Diagnosis?

Bilateral Nodules of the Hands and Feet

Lidiya Didenko1 • Maaria Chaudhry2 • Kirill Alekseyev, MD, MBA3 • Mohammad Umar Farooq, MD4 • Bilal Chaudhry, MD5

    1Medical Student, American University of Antigua, Antigua and Barbuda
    2Medical Student, Saint Louis University School of Medicine, St. Louis, Missouri
    3Medical Director, Post-Acute Medical Rehabilitation Hospital of Dover, Dover, Delaware
    4Internist, Christiana Care Health System, Newark, Delaware
    5Pulmonologist, Christiana Care Health System, Newark, Delaware

    Didenko L, Chaudhry M, Alekseyev K, Farooq MU, Chaudhry B. Bilateral nodules of the hands and feet. Consultant.
    2023;63(3):e4. doi:10.25270/con.2022.07.000012

    Received December 29, 2021. Accepted February 3, 2022. Published online July 19, 2022.

    The authors report no relevant financial relationships.

    The authors report that informed patient consent was obtained for publication of the images used herein.

    Maaria Chaudhry, Saint Louis University School of Medicine, 1N Grand Blvd, St. Louis, MO 63103 (

    A 49-year-old man presented for evaluation of a 10-year history of progressive pain in his joints. The joint pain is localized predominantly in his hands and feet. The pain is worsened with activity and is episodic. It hampers the use of the patient’s hands. The patient does not experience fatigue. The joints are not warm to the touch.

    History.  The patient was otherwise healthy. He reported no alcohol use or adherence to a particular diet. There is no history of trauma or injury to the hands.

    Physical examination. The patient is afebrile, and his vital signs are within normal limits. The chest is clear to auscultation. Firm, asymmetrical nodules are noted bilaterally over the interphalangeal and metacarpal joints of the hands (Figure); similar nodules are present near the interphalangeal and metatarsophalangeal joints of the feet. The remainder of the physical examination is unremarkable. The patient reports no stiffness or inflammation in other parts of the body.

    Diagnostic studies. Results of a comprehensive metabolic profile show an elevated leukocyte count, erythrocyte sedimentation rate, and C-reactive protein level. Microscopic examination of synovial fluid aspirate reveals needle-shaped crystals; culture results are pending.

    Tophaceous gout

    Figure. Firm, asymmetrical nodules over the interphalangeal and metacarpal joints of the hands.


    What is the most likely diagnosis?

    A. Osteoarthritis
    B. Rheumatoid arthritis
    C. Septic arthritis
    D. Tophaceous gout


    Answer and discussion on next page.