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For personal use only; all rights reserved

MR
Joseph

S. Vu1

Imaging

OBJECTIVE.

Christine

Chung1

Michael
Theodora

Recht2
Dailiana1

ever,

gout

tophus
obtained

formed

routinely

proton

-,

examinations.

soft-tissue

from

patients

one

patient

3 months

to more

gouty

decrease

Erosion

in signal

of adjacent

row edema

were

persistent

on

TI-

could

be related

ferential

When

faced

tory

quite

all the tophi

when

if the

adjacent

with

this

12, 1996; accepted

order. The
ment leading

eventually

of Radiology,

Ohio State University

Medical

Center, S.209 Rhodes Hall, 450W. 10th Ave., Columbus,

43210. Address correspondence
to J. S. Vu.
2

Department

Cleveland,

of Radiology,

Cleveland

OH 44195.

Clinic

develop

Foundation,

OH

chronic
opment
sodes

ofgouty

arthritis

presence

of

mass

in the

American

result

in a misdiagnosis

1997

clinical

soft-tissue

0361-803X197/1682-523

AJR:168, February

unite

attack

absence

of

[2,

of gouty
the

presentation,

disease

of infection

revealed

of

an

a heterogeenhancement.
and

bone

may

or neo-

it helpful

urate

mar-

to obtain

[2,

the

The

intensity,

are

involved.

clinical

the MR imaging

and

soft-tissue

enhancement

contrast

may

MR

imaging

his-

then

be

appear-

was to deter-

study

findings

tophi
after

imaging

of this

mine

of gout

joints

gout has not been described

purpose

and

of intraosseous
the

patterns

IV administration

of

of a pare-

agent.

and Methods

study

was

with

prompted

soft-tissue

and the other in the ankle,

a

in the dif-

signal

a further

MR

4-8].
Moreover,

ance of tophaceous

presented

is conintensity

level.

obtained.

Our

gout
signal

be considered

or if other

Materials

and
or

should

changes

magnetic

31. Rarely,

inflammation
articular

sites

in

to intermediate

in detail.

level

represents

is unusual

of interme-

tophaceous

low

plasm

dis-

however, tophi may be noted at the time of the

first attack of gout [4]. Occasionally,
a tophus
the

Roentgen Ray Society

serum

find

serum

phase of the disease process. The develof a tophus in the absence of prior epi-

may have an atypical

AJR 1997;1 68:523-527

may

only a minority

gout

were

showed

variability

gout

erosive

the patients

an acute

an iso-

duration

edema,

with

This

Tophaceous

typical

rheumatologic

an elevated

in patients

heterogeneously

radiologists

although

with

The

homogeneous

soft-tissue

images.

biochemical
derangeto the development
of

I 1. Tophaceous

arthritis

Presented at the annual meeting of the American

Roentgen Ray Society, San Diego, May 1996.
1Department

with

of tophi

a tophus.
shows

situation,

out is a common

of patients

after revision

bone

showed

effusion,

T2-weighted

reveals

evaluating

gout is hyperuricemia,
Received February
July 18, 1996.

within

three

findings

findings.

on

a mass

images.

for all

The

patients

10 studies

42-70

obtained

swelling.

Nearly

tophus

joint

appearance

variable

to calcium

and recommend

associated

The MR

but

diagnosis

particularly

pannus,

were

per-

men

images.

three

soft-tissue

20 years.

All but one

synovial

common

CONCLUSION.
stant

intensity.

bone,

may be
the MR

examinations

MR

radiographs.
articular
involvement,

than

How-

A gouty

All were

MR images

diate signal
intensity
on TI-weighted
images.
On T2-weighted
overall
increase
in the signal intensity
of the tophi, whereas
neous

imaging
arthritis.

contrast-enhanced

with

gout.

manner.

and MR imaging
was to determine

13 MR

with
spin-echo

included

the corresponding
presented
with

and

of tophaceous

or confusing

tophi.

identified

and T2-weighted

as were
patients

mass.

ranged

We

examinations

evaluation

for

unusual,

and soft-tissue
on nine

density-,

Nine

were then evaluated,

RESULTS.
Five
symptoms

period

Gout

or neoplastic
process,
purpose
of this study

METHODS.

a 27-month

used

in an atypical,

of intraosseous

AND

during

years old. TI

lated

is not

clinically

characteristics

MATERIALS

the

imaging

present

occasionally
mimics
an infectious
under these circumstances.
The

imaging

Raja Jurdi1

MR

may

ofTophaceous

was

unsuspected.

group from all the patients

and rheumatologic
clinics

by two
masses.

one

in whom
We

selected

seen

patients

who

in the hand

the diagnosis
our

patient

in the orthopedic

at our medical

center

523

Yu et al.

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over

27-month

through

March

required:

each

period
1996.

patient

from

Only

January

two

criteria

was eventually

1994

radiographically

were

calcification,

diagnosed

as

having gouty arthritis. and each underwent

at least
one MR imaging examination
of the affected
areas
as part of their initial evaluation.
Nine
patients
were identified:
all were men 42-70 years old.
Four examinations
were for evaluation of a tumor.
two for infection,
one for chronic
swelling.
and six
for acute pain and synovial
inflammatory
disease.
In tour patients. the diagnosis of gout was known
by the clinician before the MR examination.
Thirteen

MR

two thumbs.

examinations

two knees.

included

two ankles,

studies

of

and seven

feet.

MR images
were obtained
on a I .()-T magnet,
and the remainder were obtained on a I .5-T magnet. TI -weighted (500-800/15-2()
ITR rangelfE
rangel). proton density-weighted
t2(XX)-24tX)/l6-.

Two

20).

and

echo

MR images

were

tions

in the axial,

coronal,

T2-weighted

were

appropriate

one

knee

(2000-24(X)/80-l()0)
obtained
and

sagittal

planes

that

area of interest.

for the specific

examination.

spin-

for all examinaIn

gradient-recalled-echo

(5(X)120. 30 flip angle) in the coronal plane

also was obtained.
In nine of the studies.
TIweighted
sequences
(500-(X)/l5-20)
were
obtained before and after IV administration
of contra.st material. In eight of nine studies, these images
were obtained with fat saturation.
(In our institusequence

tion,

we routinely

the evaluation

administer

contrast

of a palpable

material

soft-tissue

mass,

ovial inflammatory disease, or suspected

The contrast-enhanced
images
were
immediately

after

injection

of

in

the

syn-

tumor.)

appear

On MR imaging,

(Fig.

distinct

the tophi

On T2-weighted

).

nations

of

In two

did

patella.

areas

generally

were

intensity

of the

overall

decrease

After

increase

tophi,

IV administration

of contrast

ening

or pannus

formation

joints

involved

involvement.

tophus

A joint

effusion

and

tissue

occurred

tophi

and

in

sity

in the

was

noted

with

in

with soft-

patients

(Fig. 4).

Discussion

suffering

from

arthritis

pathognomonic

patients

usually

before

these

lesion

disor5% of all

patients

presented

with articular

presented

with

disease,

increased

soft-tis-

matory

an isolated

have

had gout

for 10-12

years

become

visible

radio-

or on physical

and

reaction,

an

composed

intense

inflam-

and

present

articular

had

been

from

3 months

to more

with

than 20 years.
Five patients
before
the

had radiographs

radiographs

examination.

gout

involved.

The

in

radiographic

rotic margins,
able joint

width,

to erythema

and swelling

the

MR

ing

findings

of

erosions

overhanging
space

owing

features

well-circumscribed

cortical

and

presenting
with a solitary
mass, in one patient with persistent
of the thumb,

to us

13 areas

soft

occurs
nerve
with

raises

the

van-

soft-tissue

soft-tissue

and in one patient

with

To

524

in these
diagnosis

patients
of

gout

and in patients
was

evident

our

findings

images

soft tissues

areas

a tophus

have

by which

features

topha-

18]. In one patient

with
of the proximal
interphalangeal

on T2-weighted

on

of the

TI-weighted
images

sur-

cavity

of

[ 181.

ofdecreased

signal

we could

intensity

by calcification,
correlation
or a
quantify

the degree

finding

is

not

is well described

well

varies

was
this

in the liter-

II, 17,201.
the signal

Furthermore,

[ 17,

intermediate

likely

the

medullary

caused
no pathologic

pathognomonic

recognized

low

and

into

of calcification
in a tophus
if the calcium
not radiographically
evident,
although

further

intensity

tissues

were

is

the signal

with the intense

by the monoso-

biopsy

MR imaging.

ature[lO,

I I 6, 17].

with

and

of
and

and two patients

underwent
a percutaof a symptomatic
tophus; all three
tophi were diagnostic ofgout. It is likely that, on
neous

articulation,

patients

tissue

Our study has several limitations. Only one

patient
underwent
a complete
resection
of a

may

in three

granulation

[201.

specific

MR

crys-

enhancement

a reflection
of the
of the affected
syn-

in these

arthritis

the

that
pro-

monosodium

[ 191. The

penetrating

of

of a finger,
was

crystals

gout have not been studied

in
reports
have described
the MR

knowledge,

the

likely

crystals

pathologic

cause

associated

lesion,

urate

indicated

method

that

may

of a neoplasm

oftophi

and

A tophus
also

when

was consistent
reaction
elicited

marrow

but we

an infection,

when

response

the tophus. Also, enhancement

sheaths,
ligaments,
muscles,

tendon

the bone

of

synovitis-a

inflammatory

the synovium
was

12-

near-homoge-

tissue

hypervasculanty

rounding

on

IV administration

and the hypervascula

within

in the overly-

intraosseous

possibility

ceous gout
involvement
tophus

the

large

tophaceous
detail. Two

more,

the tophi

and,

gout

joint

whom

location

confused

inflammation

13-15].

compression

scle-

In three

(6,

be

mimics

in an atypical

of

involvement
of the knee joint, the radiographic
findings
were not diagnostic
of gout. Furtherin

tissues

with
edges,

tophi.

patients

swelling

Acute

patients,

of the

eight

process.

may

often

after

radiographic

present

a neoplastic

tophus

by a tophus

In eight

obtained

Classic

were

include

were

the

caused

available

the MR examination.

disease,

showed

synovial

elicited

that surrounds
the

pattern

hypervascular

cesses-is
tals contact

be

concentration
to low heter-

Proliferative

all

inten-

could

tophus.

of macrophages.

swelling
of the thumb. Pain and
the most common
complaints

with persis-

in signal

common.

after

material.

characterizes

dium

tent soft-tissue
swelling
were

presented

contrast

inflammatory

lymphocytes,
fibroblasts,
and foreign
body
giant cells [ I 1 , I 2]. When a solitary
tophus
presents
as a soft-tissue
mass
in the absence
of

and one patient

sue mass,

intensity
was most

all the tophi

bone

but

lesions

vascularity

of a

consider-

images

signal

enhancement

of

gout,

variability

images

Nearly
neous

[8J. A tophus

examination
[9, 101.
A tophus is a mass of urates, either crystalline
or amorphous.
surrounded
by tissue showing

Five patients

weighted

ovium

Gout is a common
rheumatologic
der, accounting
for approximately
the

findings
were

due to differences
in calcium
within a tophus. An intermediate

increased

3 mm.

Results

The

of the tophus

patients

images

on T2-weighted

nonspecific

intraosseous

tophi. Bone
marrow
edema
occurred
in the
proximity
of intraosseous
tophi only and was
seen in only three

intensity.
patterns

ogeneous

with articula

patients

on 12-weighted

signal

present

in patients

to that of muscle

The imaging

all
thick-

both

isointense

images.

material,

nearly 50% of involved

joints and varied
in
volume.
Soft-tissue
edema was a universal
finding

was

ably more variable,

ranging from homogeneous
high signal intensity
to near-homogeneous
low

an

synovial

was

five patients

of the

2).

homogeneous

ofall

tophi

of the tophus

(Fig.

10 showed

intensity

but one tophus showed intense

enhancement
(Fig. 3). Ma.sslike

intraosseous

intensity

was nearly

on short-TE

in the signal

whereas

in signal

with

the signal

tophus

exami-

three

patients

low on TI-weighted
images
and high on T2weighted
images
[17].
In our patients.
the signal
intensity
of a

of interme-

images,

an overall

showed

graphically

three

show

the tophi

radiodense.

paramagnetic

agent and over a span of approximately

not

diate and occasionally

of low signal intensity
on TI-weighted
images regardless
of location

is

acquired

did

although

intensity
gout.

for example,

ofa

pannus

that

from

tophus

For any one

rheumatoid

be in the differential

histologically

nus to fibrous

of

diagnosis.

rheumatoid

hypervascular

as the disease

[21]. As such, the signal intensity

rheumatoid
arthritis may appear

It

arthritis

pan-

progresses
of pannus of
intermediate

on
Tl -weighted
images,
heterogeneously
increased
or decreased
on 12-weighted
images,

AJR:168, February

1997

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MR

Imaging

of Tophaceous

Gout

Fig. 1.-67year-old
man with painful thumb.
A, Coronal Ti .weighted (600/1 5 ITRTIEl) MR image of thumb shows mass of intermediate signal intensity replacing soft-tissue pad at distal and volar surface of thumb. I = tophus.
B, Axial Ti -weighted (600/15) MR image shows full extent of tophus (arrows) (image magnified 1.5 times).
C, Axial contrast-enhanced
T1weighted
(600/15) MR image reveals near-homogeneous
enhancement
of mass and surrounding
edematous
subcutaneous
tissue (image
magnified

1.5 times).

Fig. 2.-60-year-old

man with pain in popliteal fossa of

knee.

A, Frontal radiograph shows lesion in anterolateral aspect of tibial plateau surrounded by faint rim of sclerosis (arrows).
B, Coronal gradient-recalledecho
(500/20 hR/TEl, 30
flip angle) MR image reveals intraosseous
tophus of
high signal intensity surrounded
by rim of low signal
intensity. Note presence of joint eftusion. I = tophus.
C and D, Sagittal proton density- and 12-weighted (2000/

20, 80 flip angle) MR images show heterogeneous mass

of intermediate
signal intensity in lateral joint line. Focal
areas of lower signal intensity on C could be due to effect
of calcium.
Note large popliteal
cyst posteriorly
(asterisk). In patients with gout rupture of popliteal cysts
is not rare and could result in symptoms that mimic acute
thrombophlebitis
or septic joint T = tophus.

AJR:i68,

February

1997

525

Yu et al.

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Fig. 3-56-year-old
man with a soft-tissue mass in the
lateral aspect of the right foot.
A, Axial Ti-weighted
(550/20 ITR/TEI) MR image
shows mass adjacent to base of fifth metatarsal bone
associated with erosive changes in cuboid and fifth
metatarsal bones. Characteristic overhanging edges
from intraosseous tophi are present in medial aspect
of fifth ray (arrows).
B, On coronal proton density (2000/20) image, extraosseous
tophus also has large plantar component
that has completely
eroded plantar surface
of fifth

metatarsal base. I = tophus.

C, Corresponding
12-weighted
(2000/80) image shows
areas of increased signal intensity, but, overall, to.
phus has decreased
in signal intensity. I = tophus.
0, Coronal fat-saturated
Ti-weighted
(600/20) image
after IV contrast administration
shows heterogeneous
enhancement
of tophus. Also seen is enhancement
of

soft tissues in deep lateral

(arrow). I = tophus.

and

enhanced

after

trast

material

[21-231.

arthropathies

such

dihydrate

ties

to gout

the

clinical

calcium

may

yield

history.

would

in the

evaluation

tissue

mass.

First,

the

ing

a history

gout
the

diagnostic

526

obtaining

be considered

the

of

MR

evaluation

ifthe

of an
with

film

rucci

We
imaging

i?it(fl(FitiO?i.

initial

not
in

3.

of patients

with

its

a mass

reveals

G. Bloch

bone.

JM.

Fine

JD,

ger pads
5.

Moschella

Fer-

diagnosis-imaging-

SL.

Diseases

In: Moschella
Philadelphia:

SD.

of nutrition

Hurley

Saunders,

and

Hi.

eds.

1985:1445

RH,
Stern
SH.
Gravallese
EM.
FG. Tophaceous
depsition
in the finwithout

gouty

1988:148:1830-1832
Kerman
BL, Mack

0.

arthritis.
Moshirfar

Arc/i

Intern

MM.

Med

Topha-

167-170

Mcdi
1982:75:773-774
8. Brower AC. Gout. In: Brower
black

images, espe-

In: Taveras

1993:32:

of

TophaRheutn

tophus.

South

Philadelphia:
Lippincott.
1991 : I - I I
R. Winkler
C. Campbell
S. Tophi as the
manifestation
of gout. Are/i
Imitern
Med

4. Shmerling
Kantrowitz

initial

gout.

C. Gout.

Radiology:

Siimg

6. Low LL, Cervantes

AG, Melcher
WL.
ceous gout as a fungating
mass. Arthritis
1992:35: 1399- I 400
7. Gisser SD, Kletter
I. Gouty
mammary

low to intermediate
the adjacent

Ankle

and

white.

AC, ed. Arthritis

Philadelphia:

Saunders.

in

1988:

257-270

9. Nakayama
DA, Barthelemy
C. Carrera
foot RW ir, Wortmann
RL. Tophaceous
and

R/ie,,,n

metabolism.

advocatthe

of

of gout

1992:152:873-876

may

of topha-

are

when

is eroding

iT. eds.

2. Wernick

of

examination.

appearance

aware

Diagnosis

on T2-weighted

mass

Dermatology.

MR

Foot

do

clinical

may

clinicians

severe

References

soft-

diagnosis

MR

be

imaging.

of heterogeneously

con-

a plain

We

compartment

gout of the foot: an unusual

presentation
chronic
gout in an undiagnosed
patient.

CCOUS

a clearly

erosions.

should

on MR

pattern

of gout.

is nonspecific.
use

important

a correct

radio-

with

are

surround-

of a periarticular

necessity

In conclusion.
ceous

two

a discussion

reveal

tumors

typical

should

cially

intensity

in the

or

radiologists

appearance

I . Hermann

to establish

Second.

these

edema

emphasizes

cepts

obviate

signal

is evident

diagnosis
as in a patient

tophus

signal intensity

1241.

study

the joint

hut

with

soft tissues

Our

low

includfibroblastic

benign

tumors, may also exhibit

on T2-weighted
images.

gout.

and
to be

processes.

and

associated

similarihowever,
values.

the
such

believe, however, that because of the occasional, atypical

presentation
of tophaceous

imag-

be expected

neoplastic

xanthofibromas

ing

MR

if

calcified

pyrophosphate
similar

especially
graphically

deposition

laboratory

findings

Several

seldom

of con-

crystal

owing to the histologic

[ 19J. In these situations.

radiographic
helpful.

administration
Other

as

disease

ing findings

ing

IV

plantar

1I

D, Niwayama
D, Niwayama

joint

disorders,

ders. 1988:1618-l671
Robbins
SL, Cotran
gouty arthritis.
In:
Kumar

V. eds.

ed. Philadelphia:
12. Garagiola
DM.
EM.

assessment.

Arthritis

1984:27:468-471

10. Resnick
Resnick
and

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G, Lightgout: a

Case

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2nd ed.

Saun-

RS, Kumar
V. Gout
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SL, Cotran

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Saunders,
Clark SA.

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1984:1356-1361
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1989:

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AJR:168, February 1997

Downloaded from www.ajronline.org by 206.53.152.37 on 01/27/14 from IP address 206.53.152.37. Copyright ARRS. For personal use only; all rights reserved

MR

Fig.4.-42-year-old

Imaging

of Tophaceous

Gout

manwith long-standing goutwho pre-

sented with pain in both feet

A. Frontal radiograph shows typical manifestations of gout
within left foot with numerous well-defined
erosions surrounded by sclerotic rims (arrows), some which have resuIted in characteristic
overhanging edges. Lesions in mid
foot are more difficult to see.
B, Axial Ti-weighted
(500/20 [TRITEI) MR image of foot

shows numerous lesions. Note characteristic

overhang-

ing edges (arrows). Most tophi are of intermediate to low

signal intensity: however, largest tophus located in first
metatarsophalangeal
(MTP)joint ofleftfoot
is revealed as
heterogeneous
in signal intensity and associated
with
bone marrow edema in adjacent bone. Similar changes
were seen in second MTP joint (not shown). I = tophus.

Cand D, Coronal proton density-andl2-weighted

(2000/20,
80 flip angle) MR images through first MTP tophus reveal
progressive, heterogeneous
increase in signal intensity. On
D, note edema in deep middle plantar compartment
(arrows) (images magnified two times).
E. Sagittal fat-saturated contrast-enhanced
Ti-weighted
(550/20) MR image shows marked enhancement
of tophus
in first MTP joint Note thattophus in dorsum of naviculocuneiform joint has not enhanced. Also note enhancement
of
marrow in first metatarsal bone (arrow) and in deep middle
plantar compartment
and plantar interosseous muscle.

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