Ultrasonographic measurement of tophi as an outcome measure for chronic gout

OBJECTIVE: To validate the usefulness of measuring tophi with ultrasonography (US) as an outcome measure for chronic tophaceous gout. METHODS: Patients with crystal-proven gout were included. To evaluate validity, intraarticular and articular deep tophi were evaluated with both magnetic resonance imaging (MRI) and US. Tophi were punctured with US guidance to evaluate face validity. Interobserver and intraobserver measurement studies were done to evaluate reliability, and to estimate the smallest detectable difference. Sensitivity to change was evaluated with a 12-month followup observational study of urate-lowering therapy. RESULTS: US detected at least one tophus in all joints where MRI found nodules considered to be tophi. There was a good correlation, but just fair agreement between measurements with US and MRI. Puncture of nodules suspected of being tophi recovered urate crystals in 83% of the procedures. Intraobserver intraclass correlation was > 0.90 for diameters and volume, while it was 0.71 to 0.83 in the interobserver study. US was found to be sensitive to change, and there was an inverse correlation between serum urate concentrations and change from baseline measurement of tophi. CONCLUSION: US measurement of tophi fulfilled the OMERACT filter for an outcome measure, although it should be tested further in randomized clinical trials.     

Bullous tophi in gout.

Two gouty patients developed bullae containing massive numbers of monosodium urate crystals. Both patients had had treatment with systemic corticosteroids. A burn precipitated one bulla, showing that local tissue injury can be a factor in tophus localization.     

Risk of hemorrhage in the knee joint following intraarticular injections

The relative and absolute blood contents in the knee joint after intraarticular injections were determined using a biochemical joint function test. Normally, only minimal amounts of blood leak into the joint cavity, but in a few cases greater quantities were found, unnoticed at the time of injection. Intraarticular injections should be done only by a specialist.     

Limited knee joint range of motion due to invisible gouty tophi

OBJECTIVES: Tophi deposits are a well-known cause of joint destruction, gouty nephropathy and spinal cord compression. This study reports another major complication of gout, namely tophi deposition causing limited knee joint excursion. METHODS: Seven gout patients with limited knee joint excursion owing to tophi deposition were studied to reveal clinical features and magnetic resonance imaging (MRI) findings. None of the patients were able to assume a full squatting posture. RESULTS: No patients had visible subcutaneous tophi over the knee joints, except for one case in which a pea-sized subcutaneous tophus was noted. Additionally, two patients even lacked visible tophi elsewhere. All knee problems in the study group were initially regarded as being due to degenerative or other internal derangements, but MRI unexpectedly revealed multiple tophaceous depositions within and around the joint. CONCLUSIONS: Intra-articular and periarticular tophi limiting knee joint range of motion are a rare but important cause of walking disability in gout patients. Although most patients do not display visible subcutaneous tophi over the knee on physical examination, the differential diagnosis should consider intra-articular tophi and MRI is valuable in this clinical setting.     

Risk factors of ultrasound-detected tophi in patients with gout

Clinical Rheumatology - Tophus is a characteristic manifestation of advanced gout, the clinical significance of which is often underestimated. This study aimed to compare the difference of clinical...     

Local tolerance of intraarticular administration of lornoxicam into the rabbit knee joint

The local tolerability of lornoxicam (Xefo^?) after single and repeated intraarticular administration was assessed in the rabbit and compared to established standard therapies (hyaluronic acid—Synvisc^? and the glucocorticoid triamcinolone—Triam^?), and the results are discussed in the context of the literature. Two local tolerance studies were performed using five male rabbits per group. Lornoxicam and competitor products were administered into the right knee joint in a volume of 500?μL. The contralateral left knee joint of the same animal was used as the control and was injected with water for injection. Three out of five animals were killed 72?h after the last administration, whereas the remaining two animals were subjected to a 2- or 6-week recovery period in the first and the second study, respectively. Findings revealed adaptive changes related to the mechanical irritation of the injection and to adaptive responses of the synoviocytes, but no signs of toxicity to bone or chondrotoxicity. Toxicokinetic analysis showed a fast and almost complete absorption of lornoxicam from the joints into the systemic circulation. As a conclusion, repeated intraarticular administration of lornoxicam was well tolerated in rabbits.     

NMR tomography of the knee joint in patients with rheumatic joint diseases

Twenty patients with rheumatoid gonarthritis were examined in a NMR tomograph with a 0.2 tesla resistive magnet. Synovial effusions were seen in 18 cases and thickening of the synovium in 15 cases. Discrimination between synovial fluid and synovium was gained by different NMR signals from various spin-echo sequences. In demonstrating a thickened synovium NMR tomography enables the depiction of inflammation inside the joint in earlier stages of illness than is possible with bone erosion detection from X-ray photographs.     

Failure of rasburicase therapy in recurrent acute gout with tophi

Rasburicase, a recombinant urate oxidase enzyme, has been used successfully in several cases of chronic tophaceous gout. We report the case of an elderly woman with chronic tophaceous gout who failed rasburicase therapy due to recurrent acute episodes of gout following each rasburicase infusion, despite prophylactic therapy.     

Computed tomography as an adjunct to ultrasound in the diagnosis of acute acalculous cholecystitis

The sonographic and computed tomographic (CT) findings were reviewed in 17 patients with acute acalculous cholecystitis (AAC) over a 6-year period from 1984 to 1989. Of the six patients in whom both ultrasound and CT were performed, CT revealed marked gallbladder (GB) wall abnormalities, including perforation, and pericholecystic fluid collections in five patients not demonstrated by sonography. Of the total group, five patients had GB wall thicknesses of less than or equal to 3 mm (normal) at pathologic examination, which demonstrated a spectrum of disease ranging from acute hemorrhagic/necrotizing, to gangrenous acalculous cholecystitis with perforation. Sonography was falsely negative or significantly underestimated the severity of AAC in seven of the 13 patients examined by sonography. CT because of its superior ability to assess pericholecystic inflammation may provide additional diagnostic information even after a thorough sonographic study in cases of AAC.     

Analysis of risk factors for susceptibility of subcutaneous tophi in people with gout

正Objective To discuss the risk factors for susceptibility of subcutaneous tophi with an aim to provide clinical evidence for the prevention and treatment of tophi.Methods A total of 5 321 cases of gout patients whose course of disease was less than 10 years were selected and divided into two groups according to whether a subcutaneous tophus was present.The clinical information was collected and relevant biochemical indices were de-     

Effect of urate-lowering therapy on the velocity of size reduction of tophi in chronic gout

OBJECTIVE: The optimal serum urate levels necessary for elimination of tissue deposits of monosodium urate in patients with chronic gout is controversial. This observational, prospective study evaluates the relationship between serum urate levels during therapy and the velocity of reduction of tophi in patients with chronic tophaceous gout. METHOD: Sixty-three patients with crystal-confirmed tophaceous gout were treated with allopurinol, benzbromarone, or combined therapy to achieve serum uric acid levels less than the threshold for saturation of urate in tissues. The tophi targeted for evaluation during followup were the largest in diameter found during physical examination. RESULTS: Patients taking benzbromarone alone or combined allopurinol and benzbromarone therapy achieved faster velocity of reduction of tophi than patients taking allopurinol alone. The velocity of tophi reduction was linearly related to the mean serum urate level during therapy. The lower the serum urate levels, the faster the velocity of tophi reduction. CONCLUSION: Serum urate levels should be lowered enough to promote dissolution of urate deposits in patients with tophaceous gout. Allopurinol and benzbromarone are equally effective when optimal serum urate levels are achieved during therapy. Combined therapy may be useful in patients who do not show enough reduction in serum urate levels with single-drug therapy.     

Detection of intraarticular abnormalities in osteoarthritis of the knee

Objective. To determine whether intraarticular abnormalities in osteoarthritis (OA) of the knee can be detected as well by needle arthroscopy as by standard arthroscopy. Methods. Needle arthroscopy followed by standard arthroscopy was performed on 10 patients with knee OA (diagnosed according to American College of Rheumatology criteria) whose symptoms were not entirely attributable to the OA and were therefore an indication for further evaluation. Each knee was assessed for abnormalities of the menisci, articular cartilage (6 sites), and synovium (6 sites). Results. Evaluation of the 18 menisci visualized with both techniques yielded the same results: 6 abnormal and 12 normal. Among the 54 articular cartilage sites evaluable with both procedures, 16 were judged normal by both needle arthroscopy and standard arthroscopy. Of the 38 cartilage sites judged abnormal by standard arthroscopy, 34 (89%) were abnormal by needle arthroscopy. Both techniques indicated cartilage changes were the same at 42 (78%) of the 54 sites; changes at the other 12 sites were 1 grade higher by standard arthroscopy than by needle arthroscopy. Both needle arthroscopy and standard arthroscopy revealed 51 evaluable sites in the synovium. Of 34 areas judged abnormal by standard arthroscopy, 24 (71%) were also judged abnormal by needle arthroscopy; 17 areas were judged normal by both techniques. The 2 techniques assigned the same macroscopic score in 27 (53%) of 51 areas of the synovium, with a higher grade by standard arthroscopy in all but 1 of the other 16 areas. Conclusion. These pilot data suggest that in knee OA, needle arthroscopy can 1) accurately detect meniscal abnormalities, 2) detect cartilage abnormalities, but may underestimate the severity, and 3) detect most synovial abnormalities, but often underestimates the severity. Needle arthroscopy is a potentially valuable rheumatologic tool for the assessment of OA of the knee.     

Moderate loading of the human osteoarthritic knee joint leads to lowering of intraarticular cartilage oligomeric matrix protein

The non-pharmacological treatment of osteoarthritis (OA) includes exercise therapy; however, little is known about the specific effect of exercise on the joint per se. The purpose of the present study was to investigate the direct effects of a load-bearing exercise upon cartilage in a single, human osteoarthritic joint determined by biochemical markers of cartilage turnover and inflammation in the synovial fluid (SF), serum and urine. Eleven subjects with OA of the knee(s), but with no other joint- or inflammatory disorders, volunteered for the study and had samples of blood, urine and synovial fluid drawn both at baseline and following 30-min one-legged knee-extension exercise. Workload: 60% of 1 RM (Repetition Maximum). Determination of cartilage oligomeric matrix protein (COMP), aggrecan, C-terminal collagen II peptide (CTX-II) and interleukin (IL)-6 were performed in synovial fluid (SF), serum and urine. A significant decrease was found in SF concentration of COMP following exercise, whereas aggrecan, CTX-II and IL-6 remained unchanged. No differences in any of the tested markers were found in serum and urine between baseline and post-exercise. Thirty minutes of mechanical loading of a single knee joint in human subjects with knee OA resulted in a reduced COMP concentration in SF.     

Intraarticular tophi in a joint without a previous gouty attack

Subcutaneous tophi are usually a late clinical manifestation of gout. However, intraarticular tophi may develop very early, since crystal shedding has been presumed to precipitate an acute gouty attack. There is little direct evidence of intraarticular tophi before the initial gouty attack. We describe a patient who had gout for 3 years without subcutaneous tophi. Whitish intraarticular deposits, presumably representing urate tophi, were noted during right knee arthroscopy for a posterior cruciate ligament tear. This observation illustrates that tophi deposition may occur early, even in previously unaffected joints.