Gout. Crystal deposition disease: Imaging perspectives. Crystal associated arthropathies. Clinical Stages of Gout 07/06/60

Transcription

1 Crystal associated arthropathies Crystal deposition disease: Imaging perspectives Warapat Virayavanich, MD Ramathibodi hospital, Mahidol University Commonly seen arthropathy MSU (gout) CPPD HADD Uncommon arthropathy Calcium oxalate aluminium phosphate Cholesterol, corticosteroid ester Xanthine Cysteine/cysteine Charcot leyden (lysophospho lipase) Asymptomatic hyperuricemia Clinical Stages of Gout Gout Acute gouty attack Intercritical gout Chronic tophaceous gout Conventional radiography remain the examination of choice Mineralization Joint space narrowing Erosion Bone proliferation Soft tissue swelling Calcification Mineralization Maintained normal bone density (until late stage) However, every arthropathy except rheumatoid arthritis maintained normal mineralization Joint space narrowing Maintained joint space 1

2 Erosion Non aggressive well circumscribed, sclerotic margin Bone production Reparative response Overhanging edge of cortex Soft tissue swelling Lumpy Bumpy soft tissue swelling Calcification Calcium precipitated with the urate crystal to verying degrees Tophi Dense nodule: cloudy, amorphous, occasionally contain distinct calcifications Eccentric, not necessarily associated with joint US findings Double contour sign Hyperechoic soft tissue area Bright dotted foci Snowstorm appearance of synovial fluid Hypervascularization (Doppler US) Tophi with or without posterior shadow Soft tissue edema CT CT more sensitive to detect erosion and tophi. Dual energy CT (DECT) allows differentiation of materials and tissues based on CT density values Image from Perez Ruiz F, et.al. Arthritis Research & Therapy 2009, 11:232 2

3 MRI MRI helps establish bone damage and erosions early in the disease Tophus: Intermediate T1/variable T2 related to amount of calcium but intermediate to lower heterogeneous signal has been reported most frequently Variable enhanced with contrast (homogeneous, heterogeneous, or peripheral enhancement*) Soft tissue or intraosseous location Distribution Random involvement Foot: 1 st MTP joint (MC in body) CPPD Confusing nomenclature of CPPD Chondrocalcinosis Pseudogout Pyrophosphate arthropathy Clinical manifestation Asymtomatic (most common form) Great mimicker 6 patterns of joint involvement Pseudogout Pseudorheumatoid Pseudoosteoarthritis (acute episode) Pseodoosteoarthritis (no acute episodes) Asymptomatic Pseudoneuropathy 3

4 Imaging characteristic Soft tissue calcification Chondrocalcinosis Synovial and capsular calcification Tendon, ligament and bursal calcification Pyrophosphate arthropathy Chondrocalcinosis Hyaline cartilage Fibrocartilage Chondrocalcinosis Hyaline cartilage Fibrocartilage CT MRI Synovial and capsular calcification MRI of chondrocalcinosis can be confusion (high or low SI on either T1 or fluid sensitive sequences Decreased sensitivity and specificity for diagnosis meniscal tear 4

5 Tendon, ligament and bursal calcification Pyrophosphate arthropathy Unusual articular distribution Unusual intra articular distribution Prominent subchondral cyst formation Severe & progressive destructive bone changes Variable osteophyte formation Hand and wrist involvement Radiocarpal joint space narrowing SLAC wrist and stepladder appearance The triscaphe joint more commonly affected in CPPD crystal disease than in OA Narrowing MCP (especially 2nnd and 3 rd ) with sparing IP joint Drooping osteophytes (radial aspect) Sclerosis, cysts or collapse metacarpal head Knee joint Isolated patellofemoral compartment Knee joint Isolated patellofemoral compartment 5

6 Clinical presentation HADD Pain, erythema, swelling, and limitation of motion of the neighboring joint Most commonly between the ages of 40 and 70 years (rare in children) HADD Characterized by periarticular calcifications, usually in tendons near their osseous attachments Usually monoarticular Tends to be self limiting with resolution of both clinical and imaging findings Acute calcific periarthritis 60% at shoulder joint (M/C) Second most common is hip (gluteus medius near greater trochanter or acetabulum, gluteus maximus attachment along the posterolateral femoral shaft of the femur Can see erosive change adjacent to area of deposition Radiographs Ultrasound 6

7 HADD and joint abnormality OA Milwaukee shoulder epitomizes HADD athropathy Elderly Mostly women (90%) Predilection for large joints (shoulder, hip, knee, elbow) Large joint effusion ( hemorrhagic and noninflammatory, extensive bone destruction, accerelated OA, intraarticular bodies 7