How can untreated gout progress to chronic tophaceous gout?

Untreated gout progresses to chronic tophaceous gout when hyperuricemia—an excess of uric acid in the blood—persists for many years, typically around a decade.1

During this period, the intermittent, self-limited attacks of acute gouty arthritis can recur and eventually involve multiple joints. The pathology shifts as chalky, pasty deposits of monosodium urate crystals begin to accumulate within the soft tissue, tendons, and cartilage. These accumulations form large, round nodules known as tophi. Once the disease reaches this chronic stage, the previously intermittent joint pain transitions into a persistent symptom.12