The hand x-ray shows

punched out lesions with overhanging margins in the distal IP joints of index & middle fingers. There is soft tissue swelling and calcification in the pulps of index & middle fingers. These features are indicative of gout. Patient had a fever and high inflammatory markers and underwent further tests to rule out associated osteomyelitis.

Distal IP joints are typically affected in osteoarthritis, gout & psoriatic arthritis whereas rheumatoid arthritis affects proximal IP joints.