【CLEAR A Daily Case】Gout

78 year old male with pain and swelling

What is the most likely diagnosis?

1.

2.

3.

4.

5.

【Answer】

4.

【discuss】

gout - hand

【Overview】

1.

2.

3.

4.

【reason】

1.

(1) Male: Female = 20:1

(2) Excessive production of uric acid

(3) Abnormal renal excretion of urate

2.

(1) Rare causes of imaging-visible disease

(2) Myeloproliferative diseases, such as (eg): polycythemia vera, leukemia, lymphoma, and multiple myeloma

(3) Cachexia

(4) Myxedema, hyperparathyroidism

(5) Chronic renal failure

(6) Glycogen storage disease

(7) Myocardial infarction

(8) Lead poisoning

Staging

1.

2.

3.
Polyarticular gout

4.
Chronic gritty gout = multiple large urate deposits

part

1.
Joints: hand + foot (the first metatarsophalangeal joint (MTP) is most commonly affected = foot gout), elbow joint, wrist joint

Carpal-metacarpal joints are especially common, knees, shoulders, hips, sacroiliac joints (15% unilateral)

2.
Auricle > bone, tendon, bursa

【Differential diagnosis】

soft tissue imaging

1.
50% of gout nodules see calcified deposits (only calcium urate crystal X-rays are opaque)

2.
Para-articular, eccentric, lobulated soft tissue mass (hand, foot, ankle, elbow, knee joint)

3.
Bilateral olecranon bursitis

4.
External auditory canal calcification

【Arthrographic manifestations】

1.
Initially the joint space is present

2.
Lack of demineralization around the joints

3.
Erosion of joint edge with sclerosis

4.
Advanced cartilage destruction in gout

5.
Swelling around the joints (acute monoarticular gout)

6.
Chondrocalcinosis (meniscus, knee cartilage) leading to secondary osteoarthritis

【Bone imaging manifestations】

1.
"Puncture-like" osteolytic lesions, with or without sclerotic borders

2.
Long-term erosion from soft tissue gout nodules is "rat bite"

3.
"Hanging-like edge" (40%)

4.
Avascular necrosis of the femoral head or humeral head

5.
Bone infarction

【Common diseases】

1.
Psoriasis

2.
Glycogen storage disease type I

3.
Hypoparathyroidism or hyperparathyroidism

4.
Down's syndrome

5.
Lesch-nyhan syndrome (chest athetosis, rigidity, mental retardation, self-mutilation of lips, fingers and toes)

【treat】

Colchicine, allopurinol (responsible treatment often does not change X-ray findings)

gout:

It can be seen that large gout stones (white arrows) surround multiple joints in the right hand, and gout can be seen beside the joints, piercing-like osteolytic erosion foci and (white and yellow circles) lacking the characteristics of osteoporosis
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Enlarged view shows erosion foci (blue arrow)
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