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.     

The advanced imaging of gouty tophi

Gout is a metabolic disorder in which there is hyperuricemia caused by an increase in production or a decrease in excretion of uric acid. Long-lasting 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. The diagnosis of gout is usually based on clinical presentation and laboratory examinations, long before any abnormality can be demonstrated with imaging. Radiography is the primary imaging modality used in the initial evaluation of gouty arthritis. Ultrasonography, CT, MRI, and nuclear medicine are seldom necessary. Occasionally a tophus has an unusual presentation and simulates neoplasm or infection prompting the utilization of cross-sectional imaging for further evaluation and surgical planning. Cross-sectional imaging is also used in areas that are difficult to visualize on radiographs such as spine, sacroiliac joints, and soft tissues.     

The advanced imaging of gouty tophi

Gout is a metabolic disorder in which there is hyperuricemia caused by an increase in production or a decrease in excretion of uric acid. Long-lasting 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. The diagnosis of gout is usually based on clinical presentation and laboratory examinations, long before any abnormality can be demonstrated with imaging. Radiography is the primary imaging modality used in the initial evaluation of gouty arthritis. Ultrasonography, CT, MRI, and nuclear medicine are seldom necessary. Occasionally a tophus has an unusual presentation and simulates neoplasm or infection prompting the utilization of cross-sectional imaging for further evaluation and surgical planning. Cross-sectional imaging is also used in areas that are difficult to visualize on radiographs such as spine, sacroiliac joints, and soft tissues.     

Rapid development of gouty tophi after diuretic therapy

Increasing attention has been drawn to the role played by diuretics in the pathogenesis of gout, particularly in the elderly. We describe an elderly woman presenting acutely with tophus formation mimicking infection, in whom diuretic therapy was responsible for her disease. Her presentation with acutely inflamed tophi without any history of joint involvement, only 3 months after starting treatment, was highly unusual.     

Pulmonic regurgitation due to valvular tophi

Documented cardiac tophi are rare and have not previously been reported to cause clinically manifest valvular disease. A 31-year-old male with complex cyanotic congenital heart disease (Taussig-Bing anomaly) and secondary tophaceous gouty arthritis is described. Terminally, he presented with clinical evidence of a brain abscess and a new semilunar regurgitant murmur. Two-dimensional echocardiography suggested vegetative lesions as the cause of the murmur. The patient was treated for infective endocarditis. At autopsy, the cause of the semilunar regurgitant murmur was shown to be sterile tophi located along the line of pulmonary valvular coaptation. Tophaceous deposits were also present in the mitral valve.     

Bilateral carpal tunnel syndrome due to gouty tophi: conservative and surgical treatment in different hands of the same patient

Abstract

Gouty tophi are an uncommon cause of carpal tunnel syndrome. We describe a case of bilateral carpal tunnel syndrome due to gouty tophi. Gouty tophi in the right wrist developed slowly, but developed acutely in flexor tendons in the left wrist. Symptoms were numbness and finger movement dysfunction in both hands. The right hand was treated surgically, while the left hand was treated by medication. Both hands improved under a well-controlled serum uremic acid level.     

Computed tomography of the knee joint as an indicator of intraarticular tophi in gout

Objective. To evaluate the utility of computed tomography (CT) of the knee joint for detecting intraarticular tophaceous deposits. Methods. A prospective study of 16 patients with gout affecting the knee was conducted. A condition for inclusion in the study was the presence of needle-shaped crystals with negative birefringence in the knee joint synovial fluid. Conventional radiography and CT were performed in each case. Results. Intraarticular opacities in the capsule and the synovium, consistent with the presence of tophaceous deposits, were found in 5 of the 16 patients (9 knee joints). The mean duration of gout was longer in the patients with intraarticular tophi than in those without tophi, and 2 of the patients with tophi had poor tolerance to antihyperuricemic therapy. Conclusion. Intraarticular opacities considered to represent tophi were observed in approximately one-third of the patients. The presence of tophi correlated with a longer duration of the disease and a poor tolerance to medication. We therefore suggest that CT of the knees could be useful in the assessment and followup of certain patients with gout.     

Characteristic appearance of large subcutaneous gouty tophi in magnetic resonance imaging

Abstract

The development of multiple large tophi in patients with gout is rare. We report magnetic resonance (MR) and histological features of large subcutaneous tophi in a 32-year-old male patient with no known arthritis. His subcutaneous lesions were confused with a neoplastic process, evaluated by MR imaging, and surgically excised after biopsy. The honeycomb-like appearance on the gadolinium-enhanced images may reflect the characteristic multilobular structure of the tophi composed of avascular urate deposits and surrounding vascularized granulation tissue.     

Characteristic appearance of large subcutaneous gouty tophi in magnetic resonance imaging

The development of multiple large tophi in patients with gout is rare. We report magnetic resonance (MR) and histological features of large subcutaneous tophi in a 32-year-old male patient with no known arthritis. His subcutaneous lesions were confused with a neoplastic process, evaluated by MR imaging, and surgically excised after biopsy. The honeycomb-like appearance on the gadolinium-enhanced images may reflect the characteristic multilobular structure of the tophi composed of avascular urate deposits and surrounding vascularized granulation tissue.     

Knee locking due to a single gouty tophus

Knee locking is a highly incapacitating condition attributable to mechanical or functional factors. Pain, mostly of capsuloligamentous or intraosseous origin, is the cause of functional locking. Meniscal injuries are the most frequent arthroscopic finding in the locked knee, due to mechanical factors. We describe a patient experiencing locking during extension whose history and examination suggested a tear of the anterior horn of the lateral meniscus of the right knee; a diagnostic/therapeutic arthroscopy revealed an intraarticular gouty tophus growing from the anterior horn of the lateral meniscus.     

How do marginal osteophytes, joint space narrowing and range of motion affect each other in patients with knee osteoarthritis

To assess the number, location, direction and size of osteophytes and the change of the joint space width (JSW) in radiographs of the tibiofemoral (TF) joint in middle-aged people with longstanding knee pain with radiographic osteoarthritis (OA), and to correlate between the range of motion (ROM). In the format of a retrospective study, the OA of both knee in 84 people, 8 men and 76 women (aged 42–77 years), with chronic knee pain at inclusion were examined. The JSW of the TF joint and the number, location, direction and size of osteophyte were evaluated using a PA view in weightbearing. The location and direction of osteophytes showed some variation at each site, particularly at the lateral tibial plateau and medial femoral trochlea. Significant correlations were found between ROM of the right and left knee and the size, location and direction of the most osteophytes. In both knees, the JSW medially was lower when compared with the lateral compartment. The mean JSW in the lateral tibiofemoral compartment of the right knee was associated with active and passive flexion degree of the patients. The mean JSW in the medial and lateral tibiofemoral compartment of the left knee correlated with BMI, and changes in the Kellgren and Lawrence grade of the patients. There was found statistically significant correlation between mechanical medial proximal tibial angle and the osteophyte size of the right and left knee. We think that definitions which incorporate both osteophytes and joint space narrowing offer the association with worsening of active and passive ROM.     

Comparison of phenotype expression by mononuclear phagocytes within subcutaneous gouty tophi and rheumatoid nodules

Summary The mononuclear phagocyte infiltrate which occupies the gout tophus has been compared with that of the subcutaneous rheumatoid nodule. In the gout tophus, macrophage migration appears to be at a relatively low level and effectively terminates once these cells have been recruited into the corona. In the nodule the evidence suggests that both macrophage and granulocyte populations continuously migrate towards, and are progressively incorporated into, the necrotic centres. These observations indicate that chemotactic activity in rheumatoid nodules is at a higher level than in gout tophi, or that the rheumatoid mononuclear phagocyte is more responsive to such stimuli.     

Females with FVIII and FIX deficiency have reduced joint range of motion

Little is known about rates of joint bleeding among females with FVIII/FIX deficiency or hemophilia carriers. In a cross‐sectional study, we tested the hypothesis that females with FVIII or FIX deficiency enrolled in the Universal Data Collection (UDC) project had a reduced mean overall joint range of motion (ROM) compared with historic controls from the Normal Joint Study. Demographics, clinical characteristics, and joint ROM measurements on 303 females without a bleeding disorder and 148 females with FVIII and FIX deficiency, respectively, between the ages of 2–69 years and a body mass index (BMI) ≤ 35 were compared. Multivariate linear regression was performed with the overall joint ROM (sum of the right and left ROM measurements of five joints) as the dependent variable and FVIII or FIX activity as the independent variable adjusting for age, race, BMI, and number of joint bleeds reported over the last 6 months. As FVIII and FIX activity decreased, the mean overall joint ROM became reduced and in most cases was significantly lower than that of the controls regardless of age and clinical hemophilia severity. Further investigation of reduced joint ROM as evidence of subclinical joint bleeding in females with FVIII and FIX deficiency is warranted. Am. J. Hematol. 89:831–836, 2014. © 2014 Wiley Periodicals, Inc.