Abstract
This study aimed at determining whether lowering serum urate (SU) to less than 6 mg/dl in patients with gout affects ultrasonographic findings. Seven joints in five patients with monosodium urate (MSU) crystal proven gout and hyperuricemia were examined over time with serial ultrasonography. Four of the five patients were treated with urate lowering drugs (ULDs) (allopurinol, n = 3; probenecid, n = 1). One patient was treated with colchicine alone. Attention was given to changes in a hyperechoic, irregular coating of the hyaline cartilage in the examined joints (double contour sign or “urate icing”). This coating was considered to represent precipitate of MSU crystals. Index joints included metacarpophalangeal (MCP) joints (n = 2), knee joints (n = 3), and first metatarsophalangeal (MTP) joints (n = 2). The interval between baseline and follow-up images ranged from 7 to 18 months. Serial SU levels were obtained during the follow-up period. During the follow-up period, three patients treated with ULD (allopurinol, n = 2; probenecid, n = 1) achieved a SU level of <6 mg/dl. In two patients, SU levels remained above 6 mg/dl (treated with allopurinol, n = 1; treated with colchicine, n = 1). At baseline, the double contour sign was seen in all patients. In those patients who achieved SU levels of <6 ml/dl, this sign had disappeared at follow-up. Disappearance of the double contour sign was seen in two knee joints, two first MTP joints, and one MCP joint. In contrast, disappearance of the double contour sign was not seen in patients who maintained a SU level ≥7 mg/dl. In one patient treated with allopurinol, SU levels improved from 13 to 7 mg/dl during the follow-up period. Decrease, but not resolution of the hyperechoic coating was seen in this patient. In the patient treated with colchicine alone, SU levels remained >8 mg/dl, and no sonographic change was observed. In our patients, sonographic signs of deposition of MSU crystals on the surface of hyaline cartilage disappeared completely if sustained normouricemia was achieved. This is the first report showing that characteristic sonographic changes are influenced by ULDs once SU levels remain ≤6 mg/dl for 7 months or more. Sonographic changes of gout correlate with SU levels and may be a non-invasive means to track changes in the uric acid pool. Larger prospective studies are needed to further assess these potentially important findings.
Similar content being viewed by others
References
Schlesinger N (2005) Diagnosis of gout: clinical, laboratory, and radiologic findings. Am J Manag Care 11:S443–S450 quiz S65–S68
Garrod AB (1859) The nature and treatment of gout and rheumatic gout. Walton and Maberly, London
Sokoloff L (1957) The pathology of gout. Metabolism 6:230–243
Sokoloff L (1965) Pathology of gout. Arthritis Rheum 8:707–713. doi:10.1002/art.1780080430
McCarty DJ (1970) Crystal-induced inflammation of the joints. Annu Rev Med 21:357–366. doi:10.1146/annurev.me.21.020170.002041
Katz WA, Schubert M (1970) The interaction of monosodium urate with connective tissue components. J Clin Invest 49:1783–1789. doi:10.1172/JCI106396
Tak HK, Cooper SM, Wilcox WR (1980) Studies on the nucleation of monosodium urate at 37 degrees C. Arthritis Rheum 23:574–580. doi:10.1002/art.1780230509
Burt HM, Dutt YC (1986) Growth of monosodium urate monohydrate crystals: effect of cartilage and synovial fluid components on in vitro growth rates. Ann Rheum Dis 45:858–864. doi:10.1136/ard.45.10.858
Bole GGJ (1985) Rheumatic diseases. In: Sodeman WAJ, Sodeman TM (eds) Pathologic physiology: mechanisms of disease. WB Saunders, Philadelphia, pp 485–513
Felig P, Havel RJ, Smith LH Jr (1985) Metabolism. In: Smith LH Jr, Thier SO (eds) Pathophysiology: the biological principles of disease. WB Saunders, Philadelphia, pp 321–439
Schumacher HR Jr (1988) Pathology of crystal deposition diseases. Rheum Dis Clin North Am 14:269–288
Remagen W (1989) Skeletal system. In: Grundmann E, Geller SA (eds) Histopathology: color atlas of organs and systems. Urban & Schwarzenberg, Munich, pp 189–202
Department of Pathology, University of Alabama at Birmingham (2006) Gout: gross natural color close-up of extensive uric acid deposits. PEIR digital library Image# 4034. Department of Pathology, University of Alabama at Birmingham, Birmingham
Thiele RG, Schlesinger N (2007) Diagnosis of gout by ultrasound. Rheumatology (Oxford) 46:1116–1121. doi:10.1093/rheumatology/kem058
Backhaus M, Burmester GR, Gerber T et al (2001) Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 60:641–649. doi:10.1136/ard.60.7.641
Chen CK, Yeh LR, Pan HB et al (1999) Intra-articular gouty tophi of the knee: CT and MR imaging in 12 patients. Skeletal Radiol 28:75–80. doi:10.1007/s002560050477
Thiele RG, Anandarajah AP, Tabechian D, Schlesinger N (2008) Comparing ultrasonography, MRI, conventional radiography, high-resolution CT and 3D rendering in patients with crystal proven gout. Ann Rheum Dis 67(Suppl II):248. doi:10.1136/ard.2007.072819
Schueller-Weidekamm C, Schueller G, Aringer M, Weber M, Kainberger F (2007) Impact of sonography in gouty arthritis: comparison with conventional radiography, clinical examination, and laboratory findings. Eur J Radiol 62:437–443. doi:10.1016/j.ejrad.2006.12.005
Rettenbacher T, Ennemoser S, Weirich H et al (2008) Diagnostic imaging of gout: comparison of high-resolution US versus conventional X-ray. Eur Radiol 18:621–630. doi:10.1007/s00330-007-0802-z
Wakefield RJ, Gibbon WW, Conaghan PG et al (2000) The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. Arthritis Rheum 43:2762–2770. doi:10.1002/1529-0131(200012)43:12<2762::AID-ANR16>3.0.CO;2-#
Yu KH (2003) Intraarticular tophi in a joint without a previous gouty attack. J Rheumatol 30:1868–1870
Wright SA, Filippucci E, McVeigh C et al (2007) High-resolution ultrasonography of the first metatarsal phalangeal joint in gout: a controlled study. Ann Rheum Dis 66:859–864. doi:10.1136/ard.2006.062802
Reginato AJ, Schumacher HR, Martinez VA (1974) The articular cartilage in familial chondrocalcinosis. Light and electron microscopic study. Arthritis Rheum 17:977–992. doi:10.1002/art.1780170611
Bjelle AO (1972) Morphological study of articular cartilage in pyrophosphate arthropathy (chondrocalcinosis articularis or calcium pyrophosphate dihydrate crystal deposition diseases). Ann Rheum Dis 31:449–456. doi:10.1136/ard.31.6.449
Grassi W, Lamanna G, Farina A, Cervini C (1999) Sonographic imaging of normal and osteoarthritic cartilage. Semin Arthritis Rheum 28:398–403. doi:10.1016/S0049-0172(99)80005-5
Filippucci E, Gutierrez Riveros M, Georgescu D, Salaffi F, Grassi W (2009) Hyaline cartilage involvement in patients with gout and calcium pyrophosphate deposition disease. An ultrasound study. Osteoarthritis Cartilage 17(2):178–181
Schlesinger N (2004) Management of acute and chronic gouty arthritis: present state-of-the-art. Drugs 64:2399–2416. doi:10.2165/00003495-200464210-00003
Pascual E, Sivera F (2007) Time required for disappearance of urate crystals from synovial fluid after successful hypouricaemic treatment relates to the duration of gout. Ann Rheum Dis 66:1056–1058. doi:10.1136/ard.2006.060368
Acknowledgments
We would like to thank Professor Peter C. Taylor and Professor Marc Feldmann for their kind review and constructive criticism.
Conflict of interest statement
The authors have declared no conflicts of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Thiele, R.G., Schlesinger, N. Ultrasonography shows disappearance of monosodium urate crystal deposition on hyaline cartilage after sustained normouricemia is achieved. Rheumatol Int 30, 495–503 (2010). https://doi.org/10.1007/s00296-009-1002-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00296-009-1002-8