Gout - wrist

Case contributed by A.Prof Frank Gaillard

Presentation

Right wrist swelling and pain.

Patient Data

Age: 60 years
Gender: Male
MRI

Abnormal florid synovial thickening and proliferation is present around the wrist most pronounced involving the radiocarpal and intercarpal joints with the hypertrophied synovium relatively low signal on T2 weighted sequences. The hypertrophied synovium fills and distends the joint recesses as well as extrudes into surrounding tendon sheath most notably the ECU and EDM. A degree of infiltration into the ECU tendon itself just beyond the level of the ulnar styloid is also noted. This abnormal synovial proliferation also results in intra-osseous extension with multiple areas of bony erosions throughout the carpus, distal radius and proximal metacarpals. Median and ulnar nerves level of the wrist are within normal limits.

Conclusion:

Pigmented villonodular synovitis (PVNS) is felt less likely given an apparent polyarticular process. A crystalline arthropathy such as gout or CPPD or in the appropriate clinical context, amyloid arthropathy are the favored diagnoses. Further evaluation with a duel energy CT of the wrist is suggested.

CT

Diffuse hyperdense synovial thickening and fluid involving the distal radioulnar, radiocarpal, intercarpal and carpometacarpal joints is stable in extent when compared to the MRI. These synovial changes again distend the adjacent joint recesses as well as extending into adjacent tendon sheath including the extensor carpi ulnaris. Associated bony erosions are again present with this hyperdense synovial proliferation also extending into these bony defects. Dual-energy CT demonstrates these hyperdensities to contain uric acid.

Conclusion:

Widespread changes of erosive tophaceous gout at the wrist.

Case Discussion

Dua energy CT is a useful way of establishing the diagnosis of gout.

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Case information

rID: 71060
Published: 26th Sep 2019
Last edited: 6th Oct 2019
Inclusion in quiz mode: Included

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