Tophaceous Material Research Articles

Can Ultrasound Differentiate Acute Erosive Arthritis Associated with Osteomyelitis, Rheumatoid Arthritis, or Gouty Arthritis?

AIM The study intended to determine the specific ultrasonographic features of acute arthritis with periarticular bone erosions caused by acute osteomyelitis (OM), rheumatoid arthritis (RA) and gouty arthritis (GA). METHOD We included 33 patients (seven with acute OM, 18 with RA flares, and eight with GA attacks) having acute monoarthritis or oligoarthritis, and receiving ultrasound (US) examinations in the acute stage. The US images were rated by three rheumatologists blinded to the diagnosis. The median scores of their evaluation of the subcutaneous tissue, periosteum, and synovium were compared. Interrater reliability was calculated using Cronbach's alpha. RESULTS The highest mean grade of subcutaneous edema appeared in patients with acute OM, and grade 2 edema was more frequent than patients with RA and GA (P = .003 and P = .026, respectively; α = .869). The prevalence of subcutaneous power Doppler signal was also higher in patients with acute OM than in those with RA and GA (P < .001 and P = .041, respectively; α = .756). Periosteal vascularity presented more frequently in acute OM (P = .003 compared with RA; P = .041 compared with GA), but the interrater reliability was poor (α = .518). The tophaceous material in GA was distinctive from OM and RA (P = .010 and P < .001, respectively; α = .774). CONCLUSION The most discriminative US features in this study were the subcutaneous tissue changes in addition to the periosteal findings. US could contribute to the differential diagnosis of acute erosive arthritis.

Imaging of gout: New tools and biomarkers?

While joint aspiration and crystal identification by polarizing microscopy remain the gold standard for diagnosing tophaceous gout, agreement among medical and ancillary health personnel examining synovial fluid using polarizing microscopy for the detection of monosodium urate (MSU) crystals appears to be poor. Imaging modalities, including conventional radiography (CR), ultrasonography (US), magnetic resonance imaging (MRI), and dual-energy computed tomography (DECT), have been found to provide information on the deposition of MSU crystals in tissues, and the consequences of such deposition. CR can demonstrate typical "punched out lesions" with marginal overhangs, but the sensitivity for erosion detection is better for DECT and US. US is inexpensive and can identify tophus deposition in and around joints, erosions, and tissue inflammation if power Doppler US is used. MRI can show tophi, bone marrow edema, and inflammation, but MRI findings of tophi may be nonspecific. DECT can identify and color-code tophaceous material, and provide an overview of the tophus burden of a joint area. Because of the lower number of available studies, the strength of evidence for the newer imaging can be improved through further research.

Unilateral milia-type intradermal tophi associated with underlying urate subcutaneous deposition: an uncommon cutaneous presentation of gout

Tophi develop during the most advanced clinical stage of gout, and are usually located on or around the joints. However, unusual skin features caused by intradermal and/or subcutaneous deposition of tophaceous material at locations other than articular regions have been reported. We present the case of a patient with a condition that has been recently termed 'miliarial gout'. which is only the second such case, to our knowledge. A 51-year-old woman, who had a chronic joint disease that had been diagnosed and treated as psoriatic arthritis, presented with multiple asymptomatic, yellowish-white, firm papules (1-3mm in size) on erythematous areas on the outside of her left leg. On histological examination of a skin biopsy, uric acid crystals were seen in the dermis and subcutis. The patient also had a raised level of serum urate, consistent with a diagnosis of gout. Treatment with allopurinol led to rapid improvement. Intake of corticosteroids and diuretics was a possible triggering factor for the development of cutaneous tophi in this patient.

AB1253 Ultrasonographic signals have additive value for gout in patients presenting with mono-/oligoarthritis

BackgroundMono-/oligoarthritis (MOA) may be evoked by intra-articular crystals or other (rheumatic) disease. Crystal proof is an important diagnostic target for clinicians aiming at longterm prophylactic pharmacotherapy in gout. Barriers of...

Tophaceous Pustule-like Rash in a Patient with Gout

To the Editor: Gout is characterized by extracellular fluid urate saturation leading to monosodium urate (MSU) crystal deposition. Typically, it manifests as recurrent acute inflammatory arthritis flares that may lead to a chronic tophaceous destructive arthritis. MSU crystal deposition usually occurs in articular and periarticular areas. MSU crystals are found in cartilage, tendon sheaths, synovial fluid, and subcutaneous tissue1. A cutaneous pustule-like rash filled with tophaceous material is a rare presentation of gout. We describe a patient with gouty arthritis presenting with an asymptomatic cutaneous diffuse rash consisting of pustule-like lesions containing tophaceous material. A 30-year-old man presented with a 6-year history of intermittent polyarticular arthritis involving the knees bilaterally, ankles bilaterally, left elbow, right fifth metacarpophalangeal (MCP) joint, and left olecranon bursitis. In addition, he had a cutaneous diffuse rash. He failed to provide a clear history regarding the time onset of the rash and its course. He did not report any pruritus, tenderness, or pain secondary to his rash. He was diagnosed as having rheumatoid arthritis by his primary doctor and was treated with naproxen, without improvement. He had no other known medical history. There was no family history of gout or kidney stones. He did not … Address correspondence to Dr. Schlesinger; E-mail: schlesna{at}umdnj.edu

Gout Affecting the Hand and Wrist

Tophaceous gout in the hand and wrist often presents de novo as the first sign of the disease process in the elderly. Tophaceous material may present in a liquid, pasty, or chalky/granular state. Treatment may be as simple as aspirating the liquid or squeezing out pasty tophaceous material. Other nonsurgical treatment options include lifestyle and dietary modifications and drug therapy. Surgery is often indicated for the patient with significant tendon and joint compromise as well as skin breakdown and for decompression of compressive peripheral neuropathy.

Diagnosis of gout by ultrasound

To establish the usefulness of ultrasonography (US) for diagnosing gout and to determine whether there are sonographic features that are characteristic for gout but not for other arthropathies. We retrospectively compared joint images of gout patients with matching images from patients with other rheumatic conditions. Images of 37 joints of 23 patients with monosodium urate (MSU) crystal-proven gout were reviewed. MSU crystals were identified in at least one joint in each patient. Our control group had 23 randomly selected patients with 33 examined joints with rheumatic conditions other than gout. Specific diagnostic features included a hyperechoic, irregular band over the superficial margin of the articular cartilage described as a double contour sign in 92% of gouty joints and in none of the controls (P < 0.001); hypoechoic to hyperechoic, inhomogeneous material surrounded by a small anechoic rim, representing tophaceous material, was seen in all gouty metatarsophalangeal (MTP) joints, in all metacarpophalangeal (MCP) joints and in none of the controls (P < 0.001); erosions adjacent to tophaceous material were seen in 65% of MTP joints and in 25% of MCP joints. One erosion was seen in a MTP joint in a control patient with psoriatic arthritis. US can detect deposition of MSU crystals on cartilaginous surfaces (P < 0.001) as well as tophaceous material and typical erosions. US may serve as a non-invasive means to diagnose gout.

Running the Numbers

### Background Asymptomatic hyperuricaemia is the most important risk factor in the development of gout, as the risk of acute arthritis rises exponentially with the serum levels of uric acid. It is a common condition, estimated at 15-20% in the general population and even though asymptomatic, approximately 20% of patients with untreated high uric acid levels develop gout over the following 5 years. Unfortunately there is not enough data available about subclinical urate crystal deposition and the joint damage that it causes. ### Objectives This study aimed to demonstrate that high levels of serum uric acid can induce changes suggestive of gout in the hyaline cartilage, joints and tendons of patients with asymptomatic hyperuricaemia. ### Method The study was a cross-sectional study on 30 patients with hyperuricaemia with no history of gout. An ultrasound examination on the knees and first methatarsophalangeal joints was performed. ### Results Synovitis was found in 7 patients (23%), 6 patients had erosions (20%), 9 patients had tophaceous material (30%) and 2 patients had DCS (6.6%). There was a slightly higher rate of findings in men than in women (8 men vs 5 women). ### Conclusion The study confirms that sustained high levels of serum uric acid can induce subclinical articular and periarticular urate deposits, synovitis and joint erosions that are detectable on ultrasound. These ultrasound findings may allow early diagnosis and treatment of gout in patients with hyperuricaemia. ### References Find all the books, read about the author, and more. See search results for this author. Are you an author? Learn about Author Central. Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH. Rheumatology, 5th ed. 2011. Doherty M. New insights into the epidemiology of gout, Rheumatology (2009) 48 (suppl 2) ii2-ii8. doi 10.1093/rheumatology/kep086. Neogi T. Asymptomatic hyperuricemia: perhaps not so benign? J Rheumatol 2008;35:734-737. Pineda C, Amezcua-Guerra LM, Solano C, Rodriguez-Henríquez P, Hernández-Díaz C, Vargas A, Hofmann F, Gutiérrez M. Joint and tendon subclinical involvement suggestive of gouty arthritis in asymptomatic hyperuricemia: an ultrasound controlled study. Arthritis Res Ther 2011 Jan 17;13(1):R4. doi: 10.1186/ar3223. De Miguel E, Puig JG, Castillo C, Peiteado D, Torres RJ, Martín-Mola E. Diagnosis of gout in patients with asymptomatic hyperuricaemia: a pilot ultrasound study. Ann Rheum Dis 2012;71:157-158. doi:10.1136/ard.2011.154997. Puig JG, De Miguel E, Castillo MC, Rocha AL, Martinez MA, Torres RJ: Asymptomatic hyperuricemia impact of ultrasonography. \[abstract\] Nucleosides Nucleotides Nucleic Acids 2008;27:592-595. Chowalloor PV, Keen HI. A systematic review of ultrasonography in gout and asymptomatic hyperuricaemia \[abstract\] Ann Rheum Dis 2013;72:5 638-645. ### Disclosure of Interest None declared

Gout in black South Africans: a clinical and genetic study.

To define the clinical characteristics of gout and determine if there were any genetic associations with gout in black South Africans. The records of 107 patients with gout seen over a five year period were retrospectively analysed. The HLA class I and class II antigens were studied in a prospective survey of 46 patients. The male to female ratio was 6.6:1. The diagnosis of gout was based on identification of monosodium urate crystals from the synovial fluid, synovial tissue or tophaceous material in 62 patients (58%) and on clinical criteria in the remaining 45 patients (42%). The mode of presentation was monoarthritis in 40 patients (37.4%), pauciarthritis in 30 (28%) and polyarthritis in 37 (34.6%). The joints which were most frequently involved were the knee in 91 patients (85%), the first metatarsophalangeal in 80 (74.8%) and the ankle in 66 (61.7%). A secondary cause was identified in 52 patients (48.6%) (diuretic therapy in 48 patients and chronic renal impairment in four); 55 patients (51.4%) had primary gout. The genetic study showed an increased frequency of HLA-B14 in patients with primary gout compared with controls. Gout is more common in black Africans than previously recognised and frequently presents with involvement of more than one joint. There was an increased frequency of HLA-B14 in patients with primary gout but the clinical significance of this is uncertain.

Urate crystals stimulate production of tumor necrosis factor alpha from human blood monocytes and synovial cells. Cytokine mRNA and protein kinetics, and cellular distribution.

Crystals of monosodium urate (MSU) provide a dose-dependent stimulus for the production by human blood monocytes of tumor necrosis factor (TNF), a cytokine with proinflammatory properties; TNF activity was inhibited selectively by monoclonal antibody to TNF alpha. Biologically active cell-associated TNF activity peaked at 3 h and was exceeded at 6 h by extracellular activity, which peaked at 12-18 h. Comparable kinetics were observed with immunoreactive TNF alpha. TNF alpha mRNA accumulation in monocytes stimulated with MSU crystals appeared as a single peak at 2-4 h, kinetics compatible with rapid production of a short half-life transcript. In contrast, crystals of calcium pyrophosphate or of hydroxyapatite did not stimulate significant production of TNF or of message. Fresh tophaceous material from a patient with gout contained significant levels of TNF alpha and cells cultured from the tophus produced TNF alpha in vitro. In rheumatoid synovial cells, spontaneous release of TNF alpha was increased by in vitro exposure to MSU crystals. Taken together with earlier work, these results support an expanded view of gouty inflammation in which the crystal-stimulated production of cytokines provides a crucial link between crystal deposition and many of the clinical and pathological facts of both acute and chronic gouty arthritis.

Tophaceous Gout Simulating Infection about a Stainless Steel Plate

A 55-year-old man developed acute symptoms suggestive of a late, deep infection 8 years after uncomplicated open reduction and internal fixation of fractures to the left ulnar and radial shafts. At the time of surgical debridement, tophaceous material was found surrounding the radial plate. Acute tophaceous gout surrounding fracture fixation devices has not been previously reported and is difficult to distinguish from a deep infection.

Tophaceous Gout Simulating Infection about a Stainless Steel Plate

Summary: A 55-year-old man developed acute symptoms suggestive of a late, deep infection 8 years after uncomplicated open reduction and internal fixation of fractures to the left ulnar and radial shafts. At the time of surgical debridement, tophaceous material was found surrounding the radial plate. Acute tophaceous gout surrounding fracture fixation devices has not been previously reported and is difficult to distinguish from a deep infection.

Crystal-induced endogenous pyrogen production. A further look at gouty inflammation.

We found previously that crystals of sodium urate and silicon dioxide (silica) can stimulate the production of endogenous pyrogen (EP), now called interleukin-1 (IL-1), the polypeptide mediator of fever and other aspects of inflammation. We have confirmed and extended the work with urate crystals and have examined 2 other crystals associated with joint problems, hydroxyapatite (HA) and calcium pyrophosphate dihydrate (CPPD). The crystals were added to suspensions of human blood leukocytes (2.5 X 10(6) monocytes/dose, with 10% fresh autologous plasma); after 18 hours of incubation, the EP content of the supernatants was assayed in the rabbit pyrogen test. HA and CPPD crystals neither induced EP production nor reduced the amount of staphylococci-induced EP. Presized (10 - 40 micron) urate crystals were pyrogenic, but less so than the unsized and aggregated urate crystals investigated previously and reexamined here. On ultrasonication, the aggregated urate crystals became first more pyrogenic and then less so as the crystals were dispersed and broken down. Ultrasound did not impart pyrogenicity to HA or CPPD crystals: their failure to stimulate EP/IL-1 production from leukocytes in vitro indicates a difference in their phlogistic properties, compared with crystals of urate or silica. The results with urate crystals have pathogenetic implications in a number of areas of gouty inflammation: initiation of the acute attack, other aspects of the acute-phase response, polyarticular involvement, and the inflammatory consequences of chronic stimulation by tophaceous material.

The Surgery of Gout in the Upper Extremity

1. Despite the development of more effective uricosuric agents for the control of the manifestations of gout, there still remain patients who fail to respond to therapy and in whom crippling deformities develop. 2. An analysis of twenty-one patients indicates that a carefully planned surgical program may offer lasting benefits in tophaceous gout of the upper extremity. 3. Large deforming masses of tophaceous material can be advantageously removed. 4. Digital function may be significantly improved. 5. Chronic infections can be better controlled. 6. Disabilities resulting from tophaceous deposits in the flexor tendons may be corrected by resecting the involved portion of tendon or excising the tophaceous mass.