Original articlePolyarticular sonographic assessment of gout: A hospital-based cross-sectional study
Introduction
Gout is one of the most prevalent inflammatory arthropathies. The classical initial manifestation of gout is acute onset of severe joint pain, most commonly affecting the 1st metatarsophalangeal joint (MTP joint), with associated swelling, erythema and exquisite tenderness. Such attacks typically resolve completely, even without treatment, although most patients experience recurrent acute attacks and may go onto develop a chronic erosive arthropathy, with characteristic radiographic appearances, or clinically detectable subcutaneous tophaceous deposits. With such classical presentations, diagnosis is relatively straightforward although definitive diagnosis requires monosodium urate (MSU) crystals to be identified by compensated polarised light microscopy of synovial fluid or tophaceous material [1]. However, clinical presentation can be atypical and diagnosis challenging. Joints characteristically affected by gout such as the 1st MTP joint and mid-tarsal joints, are not always easily amenable to joint aspiration, particularly by non-specialists.
Hence, there has been recent interest in using novel imaging modalities to diagnose gout [2], [3], [4], [5], [6], [7], [8], [9], [10]. Musculoskeletal sonography has the advantages of providing “real-time”, dynamic, high resolution images at low-cost and is becoming increasingly seen as part of everyday clinical practice in rheumatology [11], [12], [13]. Previous sonographic studies of gout have reported frequent synovial effusion, synovial hypertrophy, synovitis, and erosion even at asymptomatic joints during the intercritical period or at 1st MTP joints that have never been affected by gout [3], [4], [6]. Furthermore, the double contour sign, hyperechoic enhancement of the superficial margin of the articular cartilage, has been described as a specific sonographic feature of gout. The double contour sign was seen in 22% of 1st MTP joints in patients with gout in one study, and in at least one knee in 44% of gout patients in another study, but was absent in disease controls and normal subjects [4], [5]. However, these studies have focused largely on the 1st MTP joint or knee [4], [5], [6] with one further study recently describing findings at the MTP joints, knees and metacarpophalangeal joints (MCP joints) [9]. The only studies to have examined sonographic findings at other joint sites have examined only clinically symptomatic joints [3], [8].
In this cross-sectional observational study, we undertook a systematic sonographic examination of joints commonly affected by gout, irrespective of current or previous clinical involvement, in order:
- •
to assess the frequency of synovial effusion, synovial hypertrophy, synovitis, and double contour sign at these joints in patients with gout and;
- •
to examine how these features differ according to serum urate levels, disease duration, and use of urate-lowering therapy (ULT).
Section snippets
Methods
The study was a cross-sectional observational study undertaken in a community rheumatology hospital. Approval was obtained from the South Staffordshire Local Research Ethics Committee (09/H1203/78). Written informed consent was obtained from all participants. Procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983.
Results
Forty participants were recruited to the study. Mean age was 64.5 years (SD 13.5). Thirty-one (78%) were male. All participants fulfilled the 1977 ARA preliminary criteria [14]. The diagnosis was confirmed by identification of MSU crystals in 21 participants (53%). Tophi were present in 17 (43%). Five participants (13%) reported currently experiencing an acute attack of gout. Mean serum urate level was 441 μmol/L (SD 133) and 13 participants (33%) had a serum urate level below 360 μmol/L (6 mg/dL).
Discussion
In this hospital-based cross-sectional observational study, synovial effusion, synovial hypertrophy, and the double contour sign were very frequent sonographic findings, each being seen in at least 90% of study participants. Synovitis was seen sonographically in 62% of participants. In contrast, clinical synovitis was an infrequent finding indicating that most participants would have been considered to be in the intercritical period at the time of assessment. Synovial effusion, synovial
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
Acknowledgements
The authors would like to thank Dr Irena Zwierska for assistance with the preparation of the submission for research ethics committee approval, to the rheumatologists and research nurses at the Haywood Hospital who identified study participants, and to Professor George Peat and Dr Martyn Lewis who provided methodological and statistical advice respectively. This work was supported by the Haywood Hospital Trials and Education Fund.
References (38)
- et al.
Hyaline cartilage involvement in patients with gout and calcium pyrophosphate deposition disease. An ultrasound study
Osteoarthritis Cartilage
(2009) - et al.
Impact of sonography in gouty arthritis: comparison with conventional radiography, clinical examination, and laboratory findings
Eur J Radiol
(2007) - et al.
Gout and coronary heart disease: the Framingham Study
J Clin Epidemiol
(1988) - et al.
EULAR evidence based recommendations for gout. Part I: diagnosis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)
Ann Rheum Dis
(2006) - et al.
Development of a computed tomography method of scoring bone erosion in patients with gout: validation and clinical implications
Rheumatology (Oxford)
(2011) - et al.
Diagnosis of gout by ultrasound
Rheumatology (Oxford)
(2007) - et al.
High-resolution ultrasonography of the first metatarsal phalangeal joint in gout: a controlled study
Ann Rheum Dis
(2007) - et al.
Ultrasound imaging for the rheumatologist. XXV. Sonographic assessment of the knee in patients with gout and calcium pyrophosphate deposition disease
Clin Exp Rheumatol
(2010) - et al.
An analysis of MRI and ultrasound imaging in patients with gout who have normal plain radiographs
Rheumatology (Oxford)
(2009) - et al.
Diagnostic imaging of gout: comparison of high-resolution US versus conventional X-ray
Eur Radiol
(2008)
An exploratory ultrasound study of early gout
Clin Exp Rheumatol
Usefulness of ultrasonography for gout
Joint Bone Spine
The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI
Am J Roentgenol
Musculoskeletal ultrasonography: what is it and should training be compulsory for rheumatologists?
Rheumatology (Oxford)
Ultrasonography in rheumatology: developing its potential in clinical practice and research
Rheumatology (Oxford)
Preliminary criteria for the classification of the acute arthritis of primary gout
Arthritis Rheum
Should oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease
Ann Rheum Dis
Guidelines for musculoskeletal ultrasound in rheumatology
Ann Rheum Dis
Treatment of chronic gout. Can we determine when urate stores are depleted enough to prevent attacks of gout?
J Rheumatol
Cited by (26)
Metabolomics analysis reveals four biomarkers associated with the gouty arthritis progression in patients with sequential stages
2022, Seminars in Arthritis and RheumatismCitation Excerpt :Long-term and repeated circulation of ISAGA and AGA can lead to the deposition of tophus and eventually to chronic tophaceous gouty arthropathy (CTGA) [2]. Other complications include chronic renal injury, ureteral calculus and arthritis deformity [3,4]. GA causes swelling, intense pain and a gradual loss of function that can eventually lead to joint deformities that require surgery to remove tophus or even amputation.
Ultrasound Imaging Acquisition Procedures for Evaluating the First Metatarsophalangeal Joint: A Scoping Review
2022, Ultrasound in Medicine and BiologyCitation Excerpt :Dynamic examination involving flexion–extension of the first MTPJ was reported by one study (Pineda et al. 2011). Roddy et al. (2013) and Terslev et al. (2015) reported dynamic manoeuvres but failed to report if it was the transducer or the first MTPJ that was dynamic during the USI examination. With respect to 3-D USI, the acquisition of the USI volume consists of an automatic sweeping scan movement of the piezoelectric crystals located inside the transducer, not a sweep of the transducer over the joint surface (Naredo et al. 2013).
The popliteal groove region: A new target for the detection of monosodium urate crystal deposits in patients with gout. An ultrasound study
2019, Revue du Rhumatisme (Edition Francaise)The popliteal groove region: A new target for the detection of monosodium urate crystal deposits in patients with gout. An ultrasound study
2019, Joint Bone SpineCitation Excerpt :The knee is one of the most frequent targets of gout. US findings indicative of MSU crystal deposits have been described at knee joint and periarticular structures [14–20]. It is well known that the topographic distribution of crystal aggregates is inhomogeneous.
Ultrasonography in crystal-related diseases
2015, Revue du Rhumatisme MonographiesA diagnosis obtained by ultrasonography
2013, Revue de Medecine Interne