A tophus consists of a core of monosodium urate msu crystals surrounded by various degrees of vascularity of inflammatory tissue. Detection of uric acid depositing in tophaceous gout using a. Dualenergy computed tomography dect is a new diagnostic. Gout itself, as well as tophi development, can severely reduce mobility due to pain and stiffness in joints. Clinical applications of dualenergy computed tomography. To describe the different and lesserknown ultrasound features of tophi in chronic tophaceous gout. Findings of x rays are characteristic of tophaceous gout the typical appearance of gout on x ray evaluation is the presence of welldefined punchedout erosions with sclerotic margins in a marginal and juxtaarticular distribution, with overhanging edges. Tophus tophi plural of tophus usually appear as lumps on the skin over affected joints due to deposits of monosodium urate crystals in patients with lo. Multimodality imaging of chronic tophaceous gout may be useful in clinical practice for a variety of purposes, including assessment of diseaserelated anatomical changes and monitoring of. Gout symptoms and diagnosis johns hopkins arthritis center. Imaging in rheumatology, gout an 82yearold african american male with a history of hypertension and polyarticular tophaceous gout presented to the emergency department ed with acute onset of dizziness, neck pain, and bilateral upper extremity weakness that had arisen periodically over the previous two months.
Our goal was to assess the sensitivity of dect for the detection of monosodium urate msu deposits in nontophaceous and tophaceous gout, both at the level of the patient and that of the individual joint or lesion. Dualenergy ct dect and mri are advanced imaging methods used to visualise gout pathology. Gout is a crystal arthropathy due to deposition of monosodium urate crystals in and around the joints. When images were reconstructed with two different parameter ratios for dect imaging, mri only correlated with one dect image and the other dect image did not identify any tophi. Findings of x rays are characteristic of tophaceous gout. Spinecho t1weighted and fast spinecho t2weighted images were obtained for all patients, and 2 patients had gadoliniumenhanced mr imaging studies. Hsu cy, shih tt, huang km, chen pq, sheu jj, li yw. Ct showing prepatellar soft tissue thickening and small nodular opacities of 150200 hu in density. Fourteen tophaceous gout patients and ten nontophaceous patients were recruited from a singlecenter urban academic hospital. Direct quantitative measurement of msu volume can be made with dect software. Fourteen tophaceous gout patients and ten nontophaceous patients were. Fdgpet imaging characteristics of this disorder have not been previously described. The typical cr findings in chronic tophaceous gout, which differentiate it from other inflammatory arthritides, include well defined, punched.
Mr imaging features chronic tophaceous gout typically presents as juxta. The aim of our study was to determine whether there are sonographic features that are characteristic for gout, but not for other arthropathies, which would help provide an early, noninvasive diagnostic tool. Imaging may play a useful role in this, particularly when uric acid crystals are unable to. Limited kneejoint range of motion in patients with tophaceous. Four male patients with chronic gout with tophi affecting the knee joints three cases or the olecranon processes of the elbows one case were assessed. Typically, imaging findings associated with joint inflammation are seen, as well as findings that are more specific to and even pathognomonic of gout. A research team from the johns hopkins division of rheumatology including alan baer, m. Review imaging in gout what can we learn from mri, ct, dect. During an acute attack of gout, soft tissue swelling and effusions may be seen by cr gentili, 2006, however these findings are nonspecific. Dect detected msu deposits in non tophaceous gout, with 65% sensitivity on scanning of both upper and lower extremity joints and only 18% on scanning of the crystalproven joint. Imaging and pathology studies have established a close relationship between intraosseous tophus and bone erosion. Despite the lack of major technological advances in imaging of gout. At ultrasound, the combination of joint effusion, tophus, erosion, and the double contour sign is said to be diagnostic of gout in.
To assess the feasibility and diagnostic value of detecting uric acid depositing among patients with tophaceous gout using a dual energy ct based gemstone spectral imaging gsi technology for qualitative analysis of uric acid. In addition, when tophi break through the surface of the skin, there is a risk they may become infected or ulcerated. Dualenergy computed tomography has limited sensitivity for. Recent developments in advanced imaging in gout joseph davies. Methods diagnostic singlecentre study of 40 patients with active gout, and 41 individuals with other types of joint disease. Home september 2011 volume 17 issue 6 destructive tophaceous gout. Highresolution computed tomography has been particularly helpful in exploring the pathology of gout by investigating the. To evaluate the locations and associated erosions of tophaceous gout in the knee and to reevaluate its characteristic magnetic resonance imaging features. For persistently symptomatic, unstable dip joints, arthrodesis should be considered. Magnetic resonance imaging mri allows assessing the presence of joint deposits of monosodium urate msu and bone erosions in patients with tophaceous gout.
In addition, it allows the detection of associated structural lesions, such as meniscus or ligament pathology, which can be confusing with chronic symptoms associated with urate. The diverse clinical states and sites of pathology in gout provide challenges when considering the features apparent on imaging. Last decade has brought about significant advancement in imaging technology and real scientific growth in the understanding of the pathophysiology of gout, leading to the availability of multiple effective noninvasive diagnostic imaging options for gout and treatment options fighting inflammation and controlling urate levels. Dualenergy ct for the diagnosis of gout annals of rheumatic. Apr 08, 2020 complications of tophaceous gout may become serious if the nodes are not treated. Mri is sensitive in showing softtissue and osseous abnormalities of gout, although the imaging findings are not specific. A ctguided biopsy was diagnostic for inflammatory tophaceous gout. However, for some patients, gout can be a chronic, relapsing problem with multiple severe attacks that occur at short intervals and without complete resolution of inflammation between attacks.
Mr imaging is not routinely used for evaluation of tophaceous gout. Detection of uric acid crystals in the vasculature of patients with. In chronic tophaceous gout, there are solid urate crystal collections tophi and chronic inflammatory and destructive changes in surrounding connective tissue 12. A recent study in assessing tophi compared dect imaging with mri scanning and found that results can vary depending on the software setting for dect mcqueen et al. Some patients only experience acute gout attacks which may be limited to 12 times per year or even 12 times in lifetime. Dect was performed on 11 patients with crystalproven non. For the rheumatologist, the most exciting application is the ability of dect to specifically detect deposition of monosodium urate msu crystals. The typical appearance of gout on x ray evaluation is the presence of welldefined punchedout erosions with sclerotic margins in a marginal and juxtaarticular distribution, with overhanging edges. These tophi are typically yellowwhite in color, nontender, and are typically located within the articular. Detection of uric acid crystals in the vasculature of. There are welldefined erosions involving the hallux interphalangeal and 1st. Ultrasound images of 8 affected areas were analyzed from 31 patients with gout, using highquality broadband linear transducers frequency range of 814 mhz. Figure 2 a patient 3, left knee, prepatellar tophus. Threedimensional reconstruction of helical multidetector computed tomography scan of the foot of a patient with tophaceous gout.
After discussion of the differential with radiology, we concluded that the long history of gout, added to the ct and mri findings, favored a diagnosis of tophaceous deposition. Bone erosion is a frequent complication of tophaceous gout. Sonography can be used for needle guidance to obtain tissue samples for diagnosis. Without treatment, gout can become a chronic condition and increase your risk of developing tophi and joint damage. Cr has been the traditional imaging tool in the management of rheumatic disorders.
The sensitivity was 90% in tophaceous gout, but remained inadequate. Case submitted by stephen albert, dpm, facpm 62 yo vietnam era veteran complains of pain in multiple locations of both feet, associated with weightbearing activities. Gout commonly involves specific joints and anatomic structures, and knowledge of these sites and imaging appearances are clues to the correct diagnosis. Comparison of dualenergy ct and magnetic resonance imaging with anatomical pathology researchspacemanakin repository. Dualenergy computed tomography has limited sensitivity.
Msu crystals in tophaceous deposits around joints and deposits in tendons and soft tissues are well identified by dect. The clinical presentation and imaging features are herein discussed, with an emphasis on mr imaging. Medical college, bikaner, rajasthan research article journal of. Mr imaging of tophaceous gout revisited khoo j n, tan s c abstract gout is the most common form of microcrystalline arthropathy, and does not usually pose a diagnostic challenge when patients have a typical presentation, appropriate biochemical picture and classical radiographic appearance. Gout can cause episodes of severe pain called gout attacks. May 21, 2017 the american college of rheumatologyeuropean league against rheumatism collaborative initiative has noted that gout is the most common form of inflammatory arthritis, with a prevalence of 3. Magnetic resonance imaging of tophaceous gout in the hands and wrists. While conventional radiography xray remains the most widely used form of imaging in the clinical setting and is helpful in revealing erosions in chronic gout, these new imaging tools can reveal joint damage and tophi at a much earlier stage. Fourteen tophaceous gout patients and ten non tophaceous patients were recruited from a singlecenter urban academic hospital.
Jamadar 1 department of radiology, university of michigan, east medical center drive, tc, ann arbor, mi, usa division of rheumatology, university of florida college of medicine. Edwardsmagnetic resonance imaging of tophaceous gout in the hands and wrists. Longlasting hyperuricemia causes the deposition of monosodium urate crystals in the joints and soft tissues, triggering gouty arthritis and, if not properly treated, the formation of gouty tophi. Paraparesis revealing tophaceous gout pottecher 2018.
Imaging in gout what can we learn from mri, ct, dect and us. Tophaceous gout online rheumatology lecture lecturio. Tophus formation is a result of untreated and uncontrolled chronic gout and is a surrogate for more severe gout and poor hrqol. To define the magnetic resonance mr imaging features of tophaceous gout of the spine.
Ankle joint function during walking in tophaceous gout. Among the 11 nontophaceous gout patients, seven had had gout for less than one year and nine had had more than one gout attack. A gouty tophus occasionally mimics an infectious or neoplastic process, and mr imaging may be obtained under these circumstances. All patients underwent dect scans of the neck and chest using a siemens somatom force ct scanner, and images were processed with syngovia imaging software to identify msu deposits. Gouty arthritis, multiple toes the american college of. Carroll m1, boocock m2, dalbeth n3, stewart s4, frampton c5, rome k6. Gout gout is a crystal arthropathy due to deposition of monosodium urate crystals in and around the joints. Validation of mri in the assessment of tophaceous gout. Dualenergy computed tomography dect is a recently developed advanced imaging technology with a number of clinical applications. There are many exciting new applications for advanced imaging in gout. These findings were in keeping with an intraarticular manifestation of chronic tophaceous gout. There are several characteristic ultrasound imaging findings, which include visualization of echogenic monosodium urate crystal deposition, tophus, and adjacent erosions. They usually happen if you dont treat your gout for a long time about 10 years or.
Mr imaging of tophaceous gout revisited researchgate. Tophi are a symptom of gout, a condition where uric acid crystallizes in joints like those in your feet and hands. Epidemiology typically occurs in those above 40 years. Ideally, an imaging modality should capture all aspects of disease including monosodium urate crystal deposition, acute inflammation, tophus, tissue remodelling and complications of disease. Dualenergy computed tomography dect is a new diagnostic tool for gout, but its sensitivity has not been established. Dualenergy computed tomography open access journals. The mean age of the 40 gout patients was 62 years, the. The tophus is an organized structure that consists of collections of msu crystals and chronic inflammatory tissue. All 10 patients with tophaceous gout had msu deposits evident by dect. Gouty tophi result from a second pathophysiological mechanism of immune anergy and granuloma formation allowing the concurrent. Management of tophaceous gout of the distal interphalangeal. These modalities employ multiplanar imaging and allow computerized threedimensional rendering of bone and joints including tophi and have the advantage of electronic data storage for later retrieval.
The features on xrays are consistent with gout which is a crystal arthropathy due to the deposition of monosodium urate crystals in and around th. Tophaceous gout of the lumbar spine mimicking infectious. For the secondary analyses, we classified imaging results as positive for gout if green pixilation was either observed around the index joint andor in other locations of the imaged area. Radiograph shows multiple erosions, some of which are extramarginal. A total of 26 patients with tophaceous gout and limited knee motion. Dect can accurately assess these deeper tophi, and, with the use of dedicated automat ed volume assessment software, can measure. In our patient, dect scanning revealed evidence of spontaneous dense urate deposition in both masses, which appeared green with application of dedicated post. Bone erosions near the urate crystal deposits and secondary proliferative bone changes, in addition to ct findings of lowdensity areas representing tophi, are features. However, gout may present clinically in an atypical, unusual, or confusing manner. The management of gout and its associated morbidities are expected to be transformed with the expanded role of ultrasound and dualenergy ct dect. Our goal was to assess the sensitivity of dect for the detection of monosodium urate msu deposits in non tophaceous and tophaceous gout, both at the level of the patient and that of the individual joint or lesion. However, magnetic resonance mr imaging is increasingly used as the firstline imaging modality in patients with first presentation of joint pain or mass, and tophaceous gout is frequently a. Surgical management of acute tophaceous gout of the distal interphalangeal joint is often associated with delayed wound healing.
Characteristics of nontophaceous and tophaceous gout patient. The imaging techniques that currently have a role in the imaging of gout include conventional radiography, ultrasound, computed tomography, dual energy computed tomography, magnetic resonance imaging and nuclear medicine. Patients with chronic uncontrolled hyperuricemia, such as those with chronic kidney disease, may develop chronic tophaceous gout. Computed tomography provides specific images compared with magnetic resonance imaging and ultrasonography article in annals of the rheumatic diseases 611. Multiple cortical erosions within the tarsal and metatarsal bones, particularly along the first metatarsal head and the base of the fifth metatarsal, are present. Review article imaging appearances in gout gandikotagirish, 1 davidm. Advanced imaging modalities including mri, ultrasound us, ct and dual energy ct have important applications in gout. Recent advances in the imaging of gout show promise and hopefully will lead to more accurate assessment of the activity of gout and assist in the diagnosis of atypical presentations of acute and tophaceous gout, including its response to therapy. Mr imaging findings author links open overlay panel paosheng yen md a juifeng lin md b shinyuan chen md msc b c 1 shinnzong lin md phd b. Aspiration through neighbouring uninvolved skin is a safe method of treating these tophi. Chronic tophaceous gout results from chronic hyperuricemia. Dect can identify monosodium urate msu crystals in people with gout,1,2 and also has conventional ct properties, allowing assessment of tophus and bone pathology.
The purpose of this study was to determine the mr imaging characteristics of intraosseous and softtissue tophi. To determine the usefulness of computed tomography ct, magnetic resonance imaging mri, and doppler ultrasonography us in providing specific images of gouty tophi. Table 2 results of dect scanning in patients with non tophaceous gout. This case describes the ct, mr, and fdgpet imaging characteristics of acute inflammatory gout. An imaging panegyric khizer razak1, surbhi gupta2, g. Ultrasound features of tophi in chronic tophaceous gout. Tophi and chronic tophaceous gout treatment the toe doctor. Small soft tissue masses are associated with these erosions, the former appearing of homogeneously low signal intensity on t1 and intermediate signal intensity on t2. Dualenergy computed tomography has limited sensitivity for non. Ultrasound has recently been identified as a promising new imaging modality for gout. Dect thus confirmed severe tophaceous gout with spinal cord compression a arrows. Pdf multimodality imaging of chronic tophaceous gout. Diagnosis of gout by ultrasound rheumatology oxford academic. Mri is another imaging method that may be used in the evaluation of gout 4.
Tophaceous gout of the lumbar spine mimicking infectious spondylodiscitis and epidural abscess. Improved understanding of the pathophysiology of gout and significant advances in imaging technology in the last decade has led to multiple noninvasive imaging techniques for the diagnosis of gout. We present the mr imaging examinations of 4 patients with spinal tophaceous gout. Gout is a metabolic disorder in which there is hyperuricemia caused by an increase in production or a decrease in excretion of uric acid. Magnetic resonance imaging of tophaceous gout taipei. This is the stage where tophi develop in your joints and the tissues around them.
Clinical applications of dualenergy computed tomography for. Imaging in gout what can we learn from mri, ct, dect and. Regions of bony lysis adjacent to soft tissue densities represent tophi. Two of the four patients with a first flare of gouty arthritis but no imaging findings of msu deposition in the index joint had green pixilation in other areas. Abstract there are many exciting new applications for advanced imaging in gout.
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