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Letter
Renal medulla in severe gout: typical findings on ultrasonography and dual-energy CT study in two patients
  1. Thomas Bardin1,2,3,
  2. Khoi Minh Tran1,
  3. Quang Dinh Nguyen1,
  4. Marine Sarfati2,
  5. Pascal Richette2,3,
  6. Nhan Thanh Vo,
  7. Valérie Bousson4,5,
  8. Jean-Michel Correas6,7
  1. 1 French-Vietnamese Research Center on Gout and Chronic diseases, Vien Gut Medical Clinic, Ho Chi Minh City, Vietnam
  2. 2 Rheumatology Department, Hôpital Lariboisière APHP, Paris, France
  3. 3 Université Paris Diderot, INSERM U1132, Paris, France
  4. 4 Université Paris Diderot, CNRS UMR 7052, Paris, France
  5. 5 Radiology Department, Hôpital Lariboisière APHP, Paris, France
  6. 6 Radiology Department, Hôpital Necker APHP, Paris, France
  7. 7 Paris Descartes University, Paris, France
  1. Correspondence to Professor Thomas Bardin, Service de Rhumatologie, Hôpital Lariboisière, Paris 75010, France; thomas.bardin{at}aphp.fr

http://dx.doi.org/10.1136/annrheumdis-2018-214174

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    Monosodium urate (MSU) crystal deposition in renal medulla, described as early as the 1800s,1 was documented by autopsy studies in the 1950s to 1970s,2 3 and later by renal biopsies.4 Renal deposits have been reported mainly in patients with gout and rarely in non-gout patients with renal failure.4 Deposits appeared to be surrounded by inflammatory granulomas and medullary fibrosis. These observations led to the description of microcrystalline gouty nephropathy, a concept that was later challenged and even denied.5

    Here, we report on two patients with severe gout and the use of modern imaging modalities to reveal widespread crystal deposition in the renal medulla.

    Patient 1 was a French 54-year-old man with Lesch–Nyhan syndrome; the gene defect was previously reported.6 The patient experienced several episodes of renal colic and had severe tophaceous gout, frequent flares, urate arthropathies and worsening dystonia. He was poorly adherent to urate-lowering drugs, and the uricaemia fluctuated over the years from rarely normal to frequently high (10–15 mg/dL). The patient took a beta-blocker for hypertension; the body mass …

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    Footnotes

    • Handling editor Josef S Smolen

    • Contributors TB was involved in the two patient care, conceived this report and wrote the manuscript draft. TMK performed the US study in HCMC. MS was involved in the first patient care and retrieved data from his file. NTV performed the DECT examination of the second patient. VB performed the DECT scan of the first patient. J-MC performed the US study of the first patients. All authors improved the manuscript and approved its final version.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Author note This letter provides the first evidence of urate crystal deposition in the renal medulla in severe gout patients by modern Imaging modalities and suggests that US should be used to look not only for urinary stones, but also for medullary crystal deposits