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Subhas N, Wu F, Fox MG, Nacey N, Aslam F, Blankenbaker DG, Caracciolo JT, DeJoseph DA, Frick MA, Jawetz ST, Said N, Sandstrom CK, Sharma A, Stensby JD, Walker EA, Chang EY. ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteoarthritis: 2022 Update. J Am Coll Radiol 2023; 20:S20-S32. [PMID: 37236743 DOI: 10.1016/j.jacr.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings among the various types of arthritis. This document provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Fangbai Wu
- Research Author, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Michael G Fox
- Program Director and Panel Chair, Mayo Clinic Arizona, Phoenix, Arizona
| | - Nicholas Nacey
- Panel Vice-Chair, University of Virginia Health System, Charlottesville, Virginia
| | - Fawad Aslam
- Mayo Clinic, Scottsdale, Arizona, Rheumatologist
| | - Donna G Blankenbaker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jamie T Caracciolo
- Section Head, Musculoskeletal Imaging, Moffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; and Chair, MSK-RADS (Bone) Committee
| | | | - Matthew A Frick
- Chair of Education, Department of Radiology, Chair of Musculoskeletal Imaging, Mayo Clinic, Rochester, Minnesota
| | | | - Nicholas Said
- Duke University Medical Center, Durham, North Carolina
| | - Claire K Sandstrom
- University of Washington Medical Center, Seattle, Washington; Committee on Emergency Radiology-GSER
| | - Akash Sharma
- Mayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Eric Y Chang
- Specialty Chair, VA San Diego Healthcare System, San Diego, California
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De Vulder N, Chen M, Huysse W, Herregods N, Verstraete K, Jans L. Case Series: Dual-Energy CT in Extra-Articular Manifestations of Gout: Main Teaching Point: Dual-energy CT is a valuable asset in the detection of extra-articular manifestations of gout. J Belg Soc Radiol 2020; 104:27. [PMID: 32524069 PMCID: PMC7274205 DOI: 10.5334/jbsr.2113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/27/2020] [Indexed: 12/27/2022] Open
Abstract
Extra-articular manifestations of gout are common. The Achilles tendon is a frequently affected site, and uric acid deposition may have harmful effects on tendon structure and function. Advanced imaging can aid in early diagnosis, follow-up of disease activity and therapy efficacy. This case series highlights the use of dual-energy CT as a tool in diagnosing gout and in detecting extra-articular manifestations.
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Affiliation(s)
| | | | | | | | | | - Lennart Jans
- Ghent University, BE
- Ghent University Hospital, BE
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Falkowski AL, Jacobson JA, Kalia V, Meyer NB, Gandikota G, Yosef M, Thiele RG. Cartilage icing and chondrocalcinosis on knee radiographs in the differentiation between gout and calcium pyrophosphate deposition. PLoS One 2020; 15:e0231508. [PMID: 32298308 PMCID: PMC7162505 DOI: 10.1371/journal.pone.0231508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/24/2020] [Indexed: 12/27/2022] Open
Abstract
Objective To determine if findings of “cartilage icing" and chondrocalcinosis on knee radiography can differentiate between gout and calcium pyrophosphate deposition (CPPD). Methods IRB-approval was obtained and informed consent was waived for this retrospective study. Electronic medical records from over 2.3 million patients were searched for keywords to identify subjects with knee aspiration-proven cases of gout or CPPD. Radiographs were reviewed by two fellowship-trained musculoskeletal radiologists in randomized order, blinded to the patients’ diagnoses. Images were evaluated regarding the presence or absence of cartilage icing, chondrocalcinosis, tophi, gastrocnemius tendon calcification, and joint effusion. Descriptive statistics, sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. Results From 49 knee radiographic studies in 46 subjects (31 males and 15 females; mean age 66±13 years), 39% (19/49) showed gout and 61% (30/49) CPPD on aspiration. On knee radiographs, cartilage icing showed a higher sensitivity for CPPD than gout (53–67% and 26%, respectively). Chondrocalcinosis also showed a higher sensitivity for CPPD than gout (50–57% versus 5%), with 95% specificity and 94% positive predictive value for diagnosis of CPPD versus gout. Soft tissue tophus-like opacities were present in gout at the patellar tendon (5%, 1/19) and at the popliteus groove in CPPD (15%, 4/27). Gastrocnemius tendon calcification was present in 30% (8/27) of subjects with CPPD, and 5% (1/19) of gout. Conclusion In subjects with joint aspiration-proven crystal disease of the knee, the radiographic finding of cartilage icing was seen in both gout and CPPD. Chondrocalcinosis (overall and hyaline cartilage) as well as gastrocnemius tendon calcification positively correlated with the diagnosis of CPPD over gout.
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Affiliation(s)
- Anna L. Falkowski
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, United States of America
- Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
- * E-mail:
| | - Jon A. Jacobson
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Vivek Kalia
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Nathaniel B. Meyer
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Girish Gandikota
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Matheos Yosef
- Michigan Institute for Clinical & Health Research (MICHR), Ann Arbor, MI, United States of America
| | - Ralf G. Thiele
- Department of Rheumatology, University of Rochester, Rochester, New York, United States of America
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Boesen M, Roemer FW, Østergaard M, Maas M, Terslev L, Guermazi A. Imaging of Common Rheumatic Joint Diseases Affecting the Upper Limbs. Radiol Clin North Am 2019; 57:1001-1034. [DOI: 10.1016/j.rcl.2019.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Kupfer S, Winklhofer S, Becker AS, Distler O, Chung CB, Alkadhi H, Finkenstaedt T. Gouty arthritis: Can we avoid unnecessary dual-energy CT examinations using prior radiographs? PLoS One 2018; 13:e0200473. [PMID: 29990381 PMCID: PMC6039044 DOI: 10.1371/journal.pone.0200473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 06/27/2018] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The dual-energy CT (DECT) algorithm for urate detection is feasible only if hyperdense deposits are present. Based on our experience, around half of the performed DECT examinations show no such deposits and thus were useless for this indication. Our diagnostic accuracy study investigates whether conventional radiographs can serve as gatekeeper test prior to DECT for reliable exclusion of such radiopaque deposits. MATERIALS AND METHODS In this retrospective study, 77 clinically indicated DECT examinations of the hand (n = 29), foot (n = 36) and ankle (n = 12) of 55 patients (13 female, mean age 62±15 years) with suspected gouty arthritis were included. Two blinded readers independently evaluated DECT, gray-scale CT images (reference standard) and corresponding standardized radiographs for the presence/location of dense soft tissue deposits. RESULTS Interreader agreement for detection of soft tissue deposits with DECT and radiographs was excellent (DECT: both readers, κ = 1; radiographs: both readers, κ = 0.94). DECT showed soft tissue deposits in 54/77 DECT (70%) scans. 30/54 scans (56%) showed deposits on the corresponding radiographs, while in 24 scans (44%) no deposits were seen on radiographs. Test performance of radiographs for soft tissue deposit detection: sensitivity 56%, specificity 100%, PPV 100%, NPV 48.9%, and accuracy 69%. Low density of the deposits was the main reasons for false-negative radiographs (19 cases, 79%), followed by superimposition of deposits by osseous structures (5 cases, 21%). CONCLUSION Conventional radiographs of the hand, foot and ankle cannot serve as a gatekeeper test for reliable exclusion of radiopaque soft tissue deposits prior to DECT.
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Affiliation(s)
- Sivert Kupfer
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sebastian Winklhofer
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Anton S. Becker
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christine B. Chung
- Department of Radiology, University of California, San Diego, School of Medicine, United States of America
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tim Finkenstaedt
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Radiology, University of California, San Diego, School of Medicine, United States of America
- * E-mail:
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Jacobson JA, Roberts CC, Bencardino JT, Appel M, Arnold E, Baccei SJ, Cassidy RC, Chang EY, Fox MG, Greenspan BS, Gyftopoulos S, Hochman MG, Mintz DN, Newman JS, Rosenberg ZS, Shah NA, Small KM, Weissman BN. ACR Appropriateness Criteria ® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis. J Am Coll Radiol 2018; 14:S81-S89. [PMID: 28473097 DOI: 10.1016/j.jacr.2017.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 02/07/2023]
Abstract
Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. This review first discusses the characteristic osseous and soft tissue abnormalities seen with inflammatory arthritis and how they may be imaged. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity as there is significant overlap of imaging findings among the various types of arthritis. This review provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Jon A Jacobson
- Principal Author, University of Michigan Medical Center, Ann Arbor, Michigan.
| | | | - Jenny T Bencardino
- Panel Vice-Chair, New York University School of Medicine, New York, New York
| | - Marc Appel
- James J. Peters VA Medical Center, Bronx, New York, American Academy of Orthopaedic Surgeons
| | - Erin Arnold
- Orthopaedics and Rheumatology of the North Shore, Skokie, Illinois. American College of Rheumatology
| | | | - R Carter Cassidy
- UK Healthcare Spine and Total Joint Service, Lexington, Kentucky. American Academy of Orthopaedic Surgeons
| | - Eric Y Chang
- VA San Diego Healthcare System, San Diego, California
| | - Michael G Fox
- University of Virginia Health System, Charlottesville, Virginia
| | | | | | - Mary G Hochman
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Nehal A Shah
- Brigham & Women's Hospital, Boston, Massachusetts
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Aslam F, Michet C. My Treatment Approach to Gout. Mayo Clin Proc 2017; 92:1234-1247. [PMID: 28778257 DOI: 10.1016/j.mayocp.2017.05.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/22/2017] [Accepted: 05/23/2017] [Indexed: 12/27/2022]
Abstract
Gout is the most common form of inflammatory arthritis in the United States. Nevertheless, gout remains misunderstood, misdiagnosed, underdiagnosed, and undertreated. Several new recommendation and guideline documents regarding the management of gout have been published in the past few years. New diagnostic modalities, such as ultrasound and dual-energy computed tomography, are now available. Newer treatment options exist, and older agents and their interactions are now better understood. This review addresses these recent diagnostic and therapeutic developments and describes our management protocol with the aim of providing the clinician with a pragmatic approach to gout management.
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Affiliation(s)
- Fawad Aslam
- Division of Rheumatology, Mayo Clinic, Scottsdale, AZ
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Louthrenoo W, Jatuworapruk K, Lhakum P, Pattamapaspong N. Performance of the 2015 American College of Rheumatology/European League Against Rheumatism gout classification criteria in Thai patients. Rheumatol Int 2017; 37:705-711. [DOI: 10.1007/s00296-017-3708-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 03/17/2017] [Indexed: 12/27/2022]
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Román Sastre MM, Vega González ML. Pyrophosphate arthropathy causing shoulder pain: Value of ultrasound in its therapeutic approach. REUMATOLOGIA CLINICA 2016; 12:351-353. [PMID: 26711842 DOI: 10.1016/j.reuma.2015.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/13/2015] [Accepted: 09/04/2015] [Indexed: 06/05/2023]
Affiliation(s)
- Mónica M Román Sastre
- Servicio de Radiodiagnóstico, Hospital Clínico Universitario San Carlos, Madrid, España.
| | - M Luisa Vega González
- Servicio de Radiodiagnóstico, Hospital Clínico Universitario San Carlos, Madrid, España
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Omoumi P, Zufferey P, Malghem J, So A. Imaging in Gout and Other Crystal-Related Arthropathies. Rheum Dis Clin North Am 2016; 42:621-644. [PMID: 27742018 DOI: 10.1016/j.rdc.2016.07.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In this article, the authors consider the manifestations of intraarticular and periarticular crystal deposits. Most cases of crystal deposits are asymptomatic and represent incidental findings at imaging. In symptomatic arthropathies, imaging can play an important role in the diagnosis and assessment of disease progression and the extent of crystal deposits. Conventional radiography is the most common imaging modality. But ultrasound, conventional computerized tomography (CT), dual-energy CT, and MRI play an increasing role. The authors review typical radiographic features of crystal-induced arthropathies and findings that help to differentiate them. The authors also emphasize the increasing role of complementary imaging techniques.
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Affiliation(s)
- Patrick Omoumi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, Lausanne 1011, Switzerland.
| | - Pascal Zufferey
- Department of Rheumatology, Lausanne University Hospital, Av Pierre Decker 5, Lausanne 1011, Switzerland
| | - Jacques Malghem
- Department of Radiology, Saint Luc University Hospital, UC Louvain, Av Hippocrate 10, Brussels 1200, Belgium
| | - Alexander So
- Department of Rheumatology, Lausanne University Hospital, Av Pierre Decker 5, Lausanne 1011, Switzerland
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Abstract
This issue provides a clinical overview of gout, focusing on prevention and screening, diagnosis, and treatment. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.
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Ventura-Ríos L, Ferrusquia-Toriz D, Saldarriaga LM. Hydroxyapatite and calcium pyrophosphate crystals mimicking gout in systemic sclerosis. ACTA ACUST UNITED AC 2016; 13:235-236. [PMID: 27247113 DOI: 10.1016/j.reuma.2016.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/29/2016] [Accepted: 04/03/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Lucio Ventura-Ríos
- Laboratorio de Ultrasonido Musculoesquelético y Articular, Instituto Nacional de Rehabilitación «Luis Guillermo Ibarra Ibarra», Ciudad de México, México.
| | - Diana Ferrusquia-Toriz
- Laboratorio de Ultrasonido Musculoesquelético y Articular, Instituto Nacional de Rehabilitación «Luis Guillermo Ibarra Ibarra», Ciudad de México, México
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Dual-Energy CT of Urate Deposits in Costal Cartilage and Intervertebral Disks of Patients With Tophaceous Gout and Age-Matched Controls. AJR Am J Roentgenol 2016; 206:1063-7. [PMID: 26958708 DOI: 10.2214/ajr.15.15356] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate whether monosodium urate (MSU) deposits could be identified within the abdomen and axial skeleton of patients with tophaceous gout using dual-energy CT (DECT). CONCLUSION DECT of the abdomen, chest wall, and spine revealed extensive MSU deposits in costal cartilages and, to a lesser extent, intervertebral disks in the male patients with gout in our study. These were quantified volumetrically. However, age-matched control subjects showed similar deposits, indicating this was not a disease-specific finding. Thus, MSU deposition in the axial skeleton may be physiologic in middle-aged men.
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Popovich I, Lee AC, Doyle A, McHaffie A, Clarke A, Reeves Q, Dalbeth N, McQueen FM. A comparative MRI study of cartilage damage in gout versus rheumatoid arthritis. J Med Imaging Radiat Oncol 2015; 59:431-435. [PMID: 25908527 DOI: 10.1111/1754-9485.12306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 02/19/2015] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) is useful for detecting joint inflammation and damage in the inflammatory arthropathies. This study aimed to investigate MRI cartilage damage and its associations with joint inflammation in patients with gout compared with a group with rheumatoid arthritis (RA). METHODS Forty patients with gout and 38 with seropositive RA underwent 3T-MRI of the wrist with assessment of cartilage damage at six carpal sites, using established scoring systems. Synovitis and bone oedema (BME) were graded according to Rheumatoid Arthritis MRI Scoring System criteria. Cartilage damage was compared between the groups adjusting for synovitis and disease duration using logistic regression analysis. RESULTS Compared with RA, there were fewer sites of cartilage damage and lower total damage scores in the gout group (P = 0.02 and 0.003), adjusting for their longer disease duration and lesser degree of synovitis. Cartilage damage was strongly associated with synovitis in both conditions (R = 0.59, P < 0.0001 and R = 0.52, P = 0.0045 respectively) and highly correlated with BME in RA (R = 0.69, P < 0.0001) but not in gout (R = 0.095, P = 0.56). CONCLUSIONS Cartilage damage is less severe in gout than in RA, with fewer sites affected and lower overall scores. It is associated with synovitis in both diseases, likely indicating an effect of pro-inflammatory cytokine production on cartilage integrity. However, the strong association between cartilage damage and BME observed in RA was not identified in gout. This emphasizes differences in the underlying pathophysiology of joint damage in these two conditions.
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Affiliation(s)
- Ivor Popovich
- Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
| | - Arier Cl Lee
- Department of Epidemiology and Biostatistics, Tamaki Campus, University of Auckland, Auckland, New Zealand
| | - Anthony Doyle
- Department of Radiology, Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand
| | - Alexandra McHaffie
- Department of Radiology, Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand
| | - Andrew Clarke
- Department of Radiology, Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand
| | - Quentin Reeves
- Department of Radiology, Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand
| | - Nicola Dalbeth
- Bone & Joint Research Group, Department of Medicine, University of Auckland, Auckland, New Zealand.,Department of Rheumatology, Auckland District Health Board, Greenlane Clinical Centre, Auckland, New Zealand
| | - Fiona M McQueen
- Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand.,Department of Rheumatology, Auckland District Health Board, Greenlane Clinical Centre, Auckland, New Zealand
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