1、By Bone Group2013-10-24,CASE DISCUSSION,History,Male,29YComplaint:bilateral knee pain with intermittent fever for 4 years,Key signs？Your impression？DDX？,Laboratory examinationUric Acid（UA）：478.3mol/LTreatmentAllopurinol（ALLO）,Final diagnosis,Gouty Arthritis,Background,Gout is a form of inflammatory
2、arthritis that is characterized initially by acute attacks of active synovitis related to the presence of monosodium urate (MSU) crystals in the joints and periarticular soft tissues.Accounting for 3-7 in panarthritisMen40 years oldGenetic predisposition,Background,Most classically in the first meta
3、tarsophalangeal joint (toe)A history of underlying renal disease or use of medications that cause hyperuricemiaGold standard : monosodium urate (MSU) crystals in the joint fluid or tophus,Pathogenesis,MSU crystalsLipidsProteinMucopolysaccharidesThe tophus eroding the underlying bone is pivotal in th
4、e development of bone erosions in gouty arthritis.MSU crystal deposition is associated with the presence of underlying OA.,Radiologic hallmarks,Presence of macroscopic tophiNormal mineralizationRelative joint space preservationErosions with overhanging edgesA gradually expanding tophus eroding at th
5、e bone cortex with concomitant new periosteal bone formation trying to contain the tophusAsymmetric polyarticular distribution,X-RAY,Chronicity of the disease processOnly 45,only 6-8 years“Punched out”Until 612 years after the initial acute attack,CT,82% visible tophiLarge erosions 7.5 mm diameter,M
6、RITophi,T1WIHomogeneous and generally isointense to muscle T2WIVariedIntermediate to low heterogeneous signal intensityA variable enhancementPeripheral enhancement pattern,DDX,Chondrocalcinosis (pseudogout)Rheumatoid arthritis (RA)Pigmented villonodular synovitis（PVNS）,Chondrocalcinosis,Commonly fou
7、nd in the elderlyMostly occuring in the knee jointDeposition of different types of crystals in the hyaline articular cartilage and/or fibrous cartilage of the menisciPredominant：Calcium pyrophosphate dihydrate (CPPD)Produce severe degenerative joint disease (pyrophosphate arthropathy),Radiographic h
8、allmarks,Articular and periarticular calcificationOnly involving 1 or 2 jointsDiscrete areas of low signal intensity within the articular cartilageMore apparent on GRE sequencesJoint space narrowing Subchondral osteosclerosisArticular surface subsidence,RA,Characterized by an inflammatory synovitis
9、and a potential to destroy bone and cartilageMostly seen in middle-aged womanSymmetric distributionRF（+）,Radiologic hallmarks,Extensive and diffuse synovial hyperplasia and inflammationSynovial pannus formation Marked enhancement Serious articular cartilage degeneration（Grade or ）Local marginal eros
10、ionsObvious local osteoporosisJoint space narrowing in early stage，even fusion,PVNS,Characterized by synovial proliferation and hemosiderin deposition into the synovial tissues of the affected jointMen aged 20-40 years oldMostly seen in knee and ankle jointProliferation（villous/nodular/mixed)Nodular
11、 variety commonly seen in the tendon sheaths, principally on the volar aspect of the phalanges,Radiologic hallmarks,Variable extent of synovial proliferationJoint effusion and erosion of boneDeposit of hemosiderin within the synovial massesLow signal on both T1WI and T2WIBest seen on FFE sequence,Tr
12、eatment,ColchicineNot an accurate tool to diagnose gout(psoriatic arthritis&pseudogout)Cold applicationsA useful adjuvant treatment(RA),Conclusion,Plain radiographs are less sensitive to early changes in chronic gout than other imaging techniques. CT may be the most specific imaging technique when evaluating intraosseous lesions, while MRI could be the preferred technique to evaluate chronic synovial involvement.The presence of structural changes in radiographs correlates with poor function, and is associated with irreversibility of changes.,
