The Pathognomic Radiologic Features of Gout in the Fingers and Review of the Literature, Including the Latest Drug Therapy

doi:10.4236/ojrad.2013.33017

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Open Journal of Radiology, 2013, 3, 108-111

http://dx.doi.org/10.4236/ojrad.2013.33017 Published Online September 2013 (http://www.scirp.org/journal/ojrad)

The Pathognomic Radiologic Features of Gout in the

Fingers and Review of the Literature, Including the

Latest Drug Therapy

Mehdi Hossaini1*, Eric Tetteroo2, Frank M. A. Slaats3, Annechien Beumer4

1Department of Orthopaedic Surgery, Catharina Hospital, Eindhoven, The Netherlands

2Department of Radiology, Amphia Hospital Breda, Breda, The Netherlands

3Department of Rheumatolog y, Amphia Hospit al Breda, Breda, The Netherlands

4Department of Orthopaed ic Surgery, Amphia Hospital Breda, The Netherlands

Email: *[email protected]

Received June 27, 2013; revised July 27, 2013; accepted August 4, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Gout is one of the most common inflamma tory arthritid es that pr edominantly affects the first metatarsophalang eal joint.

The underlying inflammatory process is elicited by the deposition of monosodium urate (MSU) crystals in the affected

joint that are termed tophi and wh ich may in the course of ch ronic gout progress into subcutaneous depositions of tophi.

In this case report, we present a patient (PID: 6925981) who was seen in our outpatient department with a first episode

of tophaceous gout in the finger, an infrequently seen condition that mostly affects older men with long-term gout. We

discuss the case in view of the current literature on diagnosis and treatment of tophaceous gou t.

Keywords: Gout; Tophi; Interphalang eal Joint; Finger; Monosodium Urate; Arthritis

1. Introduction

Gout is a form of arthritis and it is one of the earliest

recognized clinical entities in medical history. Gout was

first identified by the Egyptians in 2640 BC and later

described by Hippocrates and Galen [1]. The underlying

pathophysiology is an inflammatory process induced by

deposition of monosodium urate (MSU) crystals in ar-

ticular and periarticular tissues [2], and the presence of

these negatively birefringent crystals in the aspirated

specimen of the affected joint is a prerequisite for the

diagnosis of gout. The first sign of a gouty arthritis is

usually an acute painful attack in the first metatarsopha-

langeal joint of the foot, a condition termed podagra [3],

while other joints are less frequ ently affected [4]. Gou t is

strongly associated with an increased level of uric acid in

the blood but hyperuricaemia is not required for the de-

velopment of gout and patients with hyperuricaemia may

remain asymptomatic throughout their lives [5]. Further,

gout is often associated with obesity, metabolic syn-

dromes, chronic kidney and/or cardiovascular diseases [3,

6]. The use of certain drugs such as diuretics (Furose

mide, Hydrochlorothiazide), immunosuppressant (Cyc-

losporin) and low dose Aspirin may also be correlated

with hyperuricaemia and gout [7]. The incidence of gout

is rising worldwide and this may be related to aging and

the increased prevalence of obesity [8-10]. In addition,

inadequate treatment and sedentary lifestyles with high

intakes of alcohol, protein and fructose (the only carbo-

hydrate known to increase uric acid levels) may lead to

chronic forms of gout with periodic flare-ups [11-13].

2. Case Report

An eighty year old male patient with a long history of

gout visited our outpatient department complaining of

axial pain in the proximal interphalangeal (PIP) joint of

his left third finger that was present for three weeks. Soft

tissue swelling was seen on the dorsal and palmar sides

of PIP with slightly decreased range of motion. Radio-

graphic examination (Figure 1) showed sharply margi-

nated juxta-articular erosions and marked soft tissue

swelling. Blood examination showed an elevated uric

acid level of 0.58 mmol/L (normal < 0.30). Over the

years, the patient had painful flares of gout limited to his

pedal joints when going on vacations in Mediterranean

areas, likely due to dietary changes including alcohol

*Corresponding author.

M. HOSSAINI ET AL. 109

Figure 1. Posteroanterior (A) and lateral (B) third finger

radiographs show at the proximal interphalangeal joint

typical juxta-articular “punched-out” erosions with scle-

rotic borders and overhanging edges (open arrows). There

is marked periarticular hyperdense soft tissue swelling rep-

resenting monosodium urate crystal deposits in thickened

synovia. These so-called tophi are pathognomonic for gout.

Note joint space narrowing due to cartilage destruction,

leading to secondary degenerative osseous changes and

subluxation which can be observed in chronic gout (ar-

rows).

consumption. Further, the patient was treated with Col-

chicine by the rheumatologist and he was aware of the

dietary restrictions advised to control his uric acid levels.

Next to gout, the patient was diagnosed with Polycythe-

mia Vera and he suffered from polyglobulia, thrombocy-

tosis and microcytosis. The patient did not have any

symptomatic cardiovascular and gastrointestinal abnor-

malities except for mild diarrhea related to Colchicine

treatment. After we confirmed tophaceous gout Allo-

purinol was started in order to decrease the serum uric

acid levels that resulted in remission of the gouty attack

in the patient’s finger.

3. Discussion

3.1. Chronic Gout

In the chronic course of gout, densely packed MSU cry-

stals may deposit subcutaneously in (peri) articular tissue

with subsequent jo int damage and painful episodes years

after the first acute painful attack [14]. Subcutaneous

tophi deposition are usually visible in th e helix of the ear,

over the olecranon process and on the Achilles tendons,

and less frequently in the finger joints [14,15]. There are

several case reports on tophaceous gout in the fingers

[16,17] and in most of the patients the gouty attacks are

localized in the proximal interphalangeal joints. Further,

it seems that the incidence of gouty attacks is increasing

in the past decade, notably in men older than 60 years

with the foot and spine being the most affected sites [18].

In the present case, Polycythemia Vera induced blood

dyscrasia and increased cell turnover may produce hyper-

uricaemia leading to gout [19-21]. Further, poor com-

pliance with drug treatment [22] and high protein and

fructose intake [12,13] during the vacations may also

have contributed to the development of tophi deposition

in the finger joint of the pr esent patient. In case of symp-

tomatic gout, Colchicine is the mainstay therapy for pro-

phylaxis and treatment of acute attacks while urate-low-

ering drugs such as Allopurinol are employed for long-

term management and prophylaxis of gout [5,23]. It

should be noted that novel therapies such as anti-inter-

leukin-1 (Anakinra, Canakinumab, Rilonacept), a new

xanthine oxidase inhibitor (Febuxostat) and uricolytic

drugs (Rasburicase, Pegloticase) seem to be beneficial in

treating refractory chron ic gout. In addition , they seem to

improve health-related quality of life, particularly b y pre-

venting cardiovascular comorbidities [24-26]. Drug treat-

ment aimed at lowering uric acid levels will subsequently

lead to tophi resolution and regain of full range of motion.

If drug treatment is inadequate in mobilizing tophaceous

deposits, then operative tophectomy should be consid-

ered in order to avoid permanent joint deformity and loss

of function [27].

3.2. Radiologic Features of Gout

From a radiological point of view, characteristic changes

only occur in the chronic stage of gout. Only 45% of

patients with gout manifest radiographic bone changes,

and then only 6 to 8 years after the initial attack. Fur-

thermore, radiographic abnormalities alone are not suffi-

ciently sensitive and specific for the diagnosis of gout

[28]. Gouty arthritis usually has an asymmetrical polyar-

ticular distribution with a predilectio n for the small joints

of hands and feet. The radiographic hallmarks of gout are

well-defined “punched-out” erosions with sclerotic mar-

gins in a marginal and juxta-articular distribution, with

overhanging edges. Periarticular soft tissue swelling due

to tophi deposition in synovial tissue is common. Tophi

are also found to deposit in cartilage, bone, bursae and

other places throughout the body. The periarticular tophi

may be hyperdense due to the crystals and are pathog-

nomonic for gout. In addition, absence of periarticular

osteopenia (as seen in other common inflammatory ar-

thritides) and preservation of joint space until late stages

of the disease are other clues to the diagnosis. Because

M. HOSSAINI ET AL.

110

the radiographic findings may at times be confusing and

appear quite unusual, it may be helpful to remember,

“When in doubt, think gout” [29]. However, the refine-

ment in detecting tophi deposition using ultrasound [30,

31] and dual energy computed tomography (CT) has

made it easier to diagnose gout [32]. This will enable us

to more accurately determine the consequence of tophi

depositions on joint deformity and functional impair-

ments and to monitor the effect of urate-lowering drugs

on tophi formation. These outcomes might encourage

new therapeutic approaches in the management and fol-

low-up of patients with gout.

4. Conclusion

In conclusion, patients with chronic gout may complain

of pain in the interphalangeal joints as a result of tophi

deposition that may lead to (peri) articular changes visi-

ble on radiographic examinations. Adequate therapy in-

cludes dissuading the patient from high alcohol, protein

and fructose diets and treatment with up-to-date drugs.

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