Imaging in the Crystal Arthropathies

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Key points

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    Advanced imaging in gout using computed tomography (CT) scanning, dual-energy CT (DECT), and magnetic resonance imaging (MRI) has revealed the close association between erosions and tophi suggesting a mechanistic link.

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    The ultrasound double-contour sign in gout is likely to represent monosodium urate crystals deposited over hyaline cartilage, and often appears adjacent to tophi.

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    Some imaging techniques, especially ultrasonography, CT, and DECT, may be useful to reveal tophus resolution during

Radiography

Most often the radiographic appearance of acute gout, especially at the time of the first attack, is nonspecific. Plain radiographs (XRs) are frequently normal apart from soft-tissue swelling in the affected region, and typical gouty erosions can take up to 10 years to develop as timed from the first attack.5, 6 However, plain radiography is part of the workup of acute gout not only to look for erosions but also to help exclude other differential diagnoses and investigate for possible

Radiography

CPPD crystal deposition disease is a common form of crystalline arthropathy characterized clinically by a variety of patterns including the most common asymptomatic state (radiographic chondrocalcinosis, Fig. 7), acute monoarthritis (pseudogout), and a symmetric polyarticular destructive arthropathy that mimics RA.56 A formal diagnosis of CPPD crystal deposition disease requires synovial fluid analysis and the finding of typical rhomboidal crystals with specific birefringence characteristics.

Radiography and CT Scanning

Calcium hydroxyapatite is the largest mineral component of bone. HA crystals are small (70–300 nm in diameter) and may be difficult to identify from synovial fluid, but have been characterized as having a “shiny coin” appearance on phase-contrast light microscopy, with distinctive morphology on transmission and scanning electron microscopy.64, 65 HA deposition disease may occur in patients with renal failure in the form of tumoral calcinosis.65 A more common presentation is in older patients

Summary

There have been recent exciting advances in imaging that are directly relevant to the diagnosis and management of the crystal arthropathies. CT and DECT are important additions in gout diagnosis, revealing the volume and distribution of tophi in vastly better detail than could be gleaned previously from XRs. However, these modalities entail exposure to ionizing radiation and are not as widely available as plain radiography. As in other forms of arthritis, MRI and US inform about the

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    The authors confirm that they have not received any financial support or benefits from commercial sources for the work reported in this article. The authors have no financial interests that would create a conflict of interest with regard to this work.

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