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Age / Sex : 63 / M
Chief complaint: right knee pain and tenderness for 1 year
1) What is your impression?
Two weeks later, you can see the final diagnosis with a brief discussion of this case.
(Quiz는 quiz일 뿐이오니 답안은 한개만 보내주시기 바라오며, 복수의 답안을 보내주시는 분은 정답이 포함되어 있더라도 부득이 semi-correct answer로 처리토록 하겠습니다.)
Courtesy: 이인숙(In Sook Lee), 부산대병원(Pusan National University Hospital)
Diagnosis: Gout of the knee
Discussion
Findings:
Lateral
radiograph (A) of right knee shows large calcification in superior portion of
patella and erosions in the patella. Multiple mass-like lesions with low signal
intensities are located in the patella, insertion sites of lateral collateral
ligament, popliteus tendon, and patellar tendon on axial and sagittal
T2-weighted images (B,C,D). Bony invasion of the mass is noted in the patella
(B). The mass lesions show mainly peripheral enhancement on fat-suppressed sagittal
T1-weighted image (E).
Diagnosis:
Gout of the knee joint
Discussion:
Gout is a metabolic disease
characterized by an increase in serum urate concentration, episodes of acute
arthritis, deposits of monosodium urate monohydrate crystals (tophi) within or
around the joints. The diagnosis of acute monoarticular gouty arthritis is
usually established with clinical and laboratory assessment. However,
monoarticular or polyarticular forms of chronic tophaceous gout may present
diagnostic difficulties, for which imaging evaluation is necessary. Globally,
the disease shows a predilection for the articulations of the lower
extremities. The most common sites of abnormality are the feet, hands, wrists,
elbows, and knees.
The early radiological signs of gout are joint
effusion and periarticular edema, caused by the deposition of the nonopaque
crystals within the synovial and cartilaginous tissues. Radiographic
examination eventually reveals a classic ‘punched-out’ lytic lesion with an
associated overhanging edge at the distal metatarsals. Multiple marginal
erosions and decreased joint space are seen at several metacarpal-phalangeal
joints. These erosions contain sclerotic borders. At MR imaging, tophi have a
wide spectrum of signal intensity characteristics, which reflect their variable
composition and relative proportions of protein content, fibrous tissue,
crystals, and hemosiderin. Most lesions are isointense relative to muscle on
T1-weighted images. On T2-weighted images, most lesions show low to
intermediate heterogeneous signal intensity, although lesions with high signal
intensity have been reported. Homogeneous and intense enhancement is frequently
observed on contrast material–enhanced images
References:
1.
Jaume
Llauger, MD • Jaume Palmer, MD. Nonseptic Monoarthritis: Imaging Features with
Clinical and Histopathologic Correlation RadioGraphics 2000; 20:S263–S278
2.
J. Terrence Jose Jerome, MBBS. Gouty arthritis. APPLIED RADIOLOGY
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