Relationship between Urate Crystal Deposits Detected by Dual-energy Computed Tomography and Bone Erosions in Symptomatic Gout Patients without Clinically Apparent Tophi

Min Kyung Chung; In Je Kim; Hyeran Hyun; Ji Young Hwang; Jisoo Lee

doi:10.4078/jrd.2019.26.2.124

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Chung, Kim, Hyun, Hwang, and Lee: Relationship between Urate Crystal Deposits Detected by Dual-energy Computed Tomography and Bone Erosions in Symptomatic Gout Patients without Clinically Apparent Tophi

Original Article

J Rheum Dis 2019;26(2):124-130.

Published online: 30 April 2019

DOI: https://doi.org/10.4078/jrd.2019.26.2.124

Relationship between Urate Crystal Deposits Detected by Dual-energy Computed Tomography and Bone Erosions in Symptomatic Gout Patients without Clinically Apparent Tophi

Min Kyung Chung¹, In Je Kim¹, Hyeran Hyun², Ji Young Hwang², Jisoo Lee¹

¹Division of Rheumatology, Department of Internal Medicine, Seoul, Korea

²Department of Radiology, Ewha Womans University School of Medicine, Seoul, Korea

Corresponding to: Jisoo Lee http://orcid.org/0000-0001-6279-7025 Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea. E-mail: leejisoo@ewha.ac.kr Ji Young Hwang http://orcid.org/0000-0001-5848-3429 Department of Radiology, Ewha Womans University School of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea. E-mail: mshjy@ewha.ac.kr

Received 26 October 20183 January 2019 Accepted 22 January 2019

This is a Open Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

Dual-energy computed tomography (DECT) allows sensitive detection of monosodium urate (MSU) crystal deposits in gout. However, the role of MSU deposits on DECT during the disease process of gout is not clear. The aim of our study was to evaluate the relationship between joint damage and MSU deposits detected by DECT in symptomatic non-tophaceous gout.

Methods

DECT scans of 51 gout patients without clinically apparent tophi were assessed. Individual ankle and foot joints and Achilles tendon insertion sites were evaluated for the presence of MSU deposits and bone erosions. The total volume of MSU crystal on DECT was quantified using an automated software program. Clinical and laboratory data at the time of the DECT evaluation were obtained from medical record.

Results

MSU deposits were detected in 92.2% of the patients evaluated. Median number and total volume of MSU deposit per patient was 5.0 and 0.6 cm³, respectively. Bone erosion was found in 54.9% of patients. MSU deposits in the first (1st) metatarsophalangeal (MTP) joints were significantly associated with presence of bone erosions (odds ratio [OR] 3.77, 95% confidence interval [CI] 1.06∼13.38, p=0.040). Older age and frequent gout attack were associated with development of bone erosion in patients with MSU deposits (OR 1.12 and 2.57, 95% CI 1.04∼1.22 and 1.02∼6.50, p-value 0.004 and 0.047, respectively).

Conclusion

MSU deposits and erosions were frequently detected by DECT in symptomatic non-tophaceous gout patients, and MSU deposits in 1st MTP joints were associated with presence of bone erosions especially in patients with older age and frequent gout attack.

Keywords: Gout, Monosodium urate, Erosion, Dual-energy computed tomography

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Figure 1.

DECT of a 59-year old man with gout. Three-dimensional VRT image of both feet shows green MSU deposits adjacent right first MTP and left second MTP joints (A). Axial DECT image of both feet with small green microtophi (B). Coronal MPR DECT image presenting green microtophi around right first and left second MTP (C). Coronal MPR multi-de-tector CT image which shows erosion on right first MTP (arrow) (D). DECT: dual-energy computed tomography, VRT: volume rendering technique, MSU: monosodium urate, MTP: meta-tarsophalangeal, MPR: multi-planar reformation.

Table 1.

Characteristics of patients (n=51)

Variable	Value
Age (yr)	48.4±15.0
Male	47 (92.2)
Comorbidity	47 (92.2)
Diabetes mellitus	5 (9.8)
Hypertension	26 (51.0)
Hyperlipidemia	43 (84.3)
Previous CV event	8 (15.7)
Chronic kidney disease	8 (15.7)
Duration of gout (yr)	2.0 (0.0∼20.0)
Gout attack/year	2.0 (0.6∼12.0)
Alcohol intake ＞20 g/d	25 (50.0)
Serum urate (mg/dL)	8.10 (3.5∼15.4)
Symptomatic joints
MTP Ankle	36 (70.6) 16 (31.4)
Mid-foot	8 (15.7)
Knee	2 (3.9)

Values are presented as mean±standard deviation, number (%), or median (range). CV: cardiovascular, MTP: metatarsophalangeal.

Table 2.

Characteristics of DECT findings (n=51)

Variable	Value
Presence of MSU deposit	47 (92.2)
Number of MSU deposit/patient	5.0 (0∼17)
Total volume of MSU deposit/patients (cm³)	0.6 (0.05∼4.86)
Sites of MSU deposit
MTP joints	43 (84.3)
1st MTP	33 (64.7)
Ankle joints	33 (64.7)
Lisfranc joints	15 (29.4)
Transverse tarsal joints*	14 (27.5)
Achilles tendons	24 (47.1)
Presence of erosion	28 (54.9)
Mean number of erosion/patient	1.0 (0∼6)
Sites of erosion MTP joints	17 (33.3)
1st MTP	17 (33.3)
Ankle joints	12 (23.5)
Lisfranc joints	11 (21.6)
Transverse tarsal joints*	7 (13.7)

Values are presented as number (%) or median (range). DECT: dual-energy computed tomography, MSU: monosodium urate, MTP: metatarsophalangeal.

^* Intertarsal, talonavicular, calcaneo-cuboidal.

Table 3.

Prevalence of erosions in joints with and without DECT MSU deposits (n=51)

Site	With MSU crystal	Without MSU crystal	Odds ratio	95% confidence interval	p-value
MTP joints	18/200 (9.0)	6/310 (1.9)	3.77	1.06∼13.38	0.040
1st MTP	18/53 (34.0)	6/49 (12.2)	3.77	1.06∼13.38	0.040
Ankle joints	8/56 (14.3)	6/46 (13.0)	1.06	0.37∼3.04	0.920
Lisfranc joints	2/21 (15.7)	14/81 (17.3)	0.50	0.10∼2.40	0.386
Transverse tarsal joints*	5/20 (25.0)	8/82 (9.8)	3.06	0.80∼11.59	0.100

Values are presented as number/total (%). Odds ratios and 95% confidence interval were estimated by the generalized estimating equation model. DECT: dual-energy computed tomography, MSU: monosodium urate, MTP: metatarsophalangeal.

^* Intertarsal, talonavicular, calcaneo-cuboidal.

Table 4.

Multivariate analysis for development of bone erosion in patients with DECT MSU deposits (n=47)

		Univariate			Multivariate*
Variable	Crude OR	95% CI	p-value	Adjusted OR	95% CI	p-value
Age	1.10	1.03∼1.17	0.003	1.12	1.04∼1.22	0.004
Male	0.00	0.00∼∞	0.999
Comorbidity
Diabetes mellitus	1.02	0.15∼6.77	0.984
Hypertension	5.04	1.40∼18.14	0.013
Hyperlipidemia	1.60	0.35∼7.38	0.547
Previous CV	4.91	0.54∼44.60	0.158
Chronic kidney disease	4.91	0.54∼4.60	0.158
Duration of gout	1.14	0.95∼1.36	0.170
Frequency of gout attack	1.84	0.93∼3.66	0.082	2.57	1.02∼6.50	0.047
Serum urate	0.81	0.52∼1.26	0.354
Average volume of MSU deposit^†	^†4.05	0.29∼56.05	0.297
Sites of MSU deposit
MTP	0.46	0.04∼4.82	0.519
Ankle	0.41	0.11∼1.57	0.194
Lisfranc	0.46	0.13∼1.60	0.221
Transverse tarsal joint^‡	0.87	0.24∼3.08	0.825
Achilles	0.20	0.06∼0.71	0.013

DECT: dual-energy computed tomography, MSU: monosodium urate, OR: odds ratio, CI: confidence interval, CV: cardiovascular, MTP: metatarsophalangeal.

^* The presented factors were selected through multivariate logistic regression analysis using backward selection process among the statistically significant factors with p-value ＜0.1 in univariate analysis.

^† Total volume of MSU deposit/number of MSU deposit

^‡ Intertarsal, talonavicular, calcaneo-cuboidal.

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