?Tophus

[Diane]

Hello,

I scanned an elderly male who has a gout hx and presented with severe 1st MTPJ pain.
The dorsal MTPJ had a very thick hypoechoic joint capsule (which i first thought was just very bad synovitis) but because of the echogenic echoes within and his history of gout (and watching your joint lecture recently), I thought it could of been tophus?

1) Is this what tophus looks like? If it is, how do you tell the difference between tophus and very severe synovitis? Would the difference just be if they have a history of gout then you are leaning more to tophus? But then synovitis is secondary to tophus as well right?

I tried looking for a double cortex sign but couldn’t spot an obvious one.

2) In retrospect, On the plantar aspect of the MTPJ, I tried to look for a double cortex sign around the MTH on the plantar aspect through the cineloop but the seasmoid seems to have been obstructing the view. Could I have seen it better with hyperextension of the toes?

(Cineloops provided)

3) On the medial aspect of the toe, there was some bony irregularity but also what seems to be some echogenic areas? Could this also be crystal deposits? (cineloop provided, wrongly labelled as “lateral”)

Thanks!

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[Stephen Bird]

Hi Diane,

This stinks of gout,

It smells of gout so much I can smell it from all the way over the other side of the Nullabor plain.

I think you have synovitis, some small crystals and some tophus.

A history of gout would clinch it,

But even if they have not had known gout I still think this is gout,

It is the correct location as well.

They could test the uric axis blood levels,

Also a joint synovial fluid aspiration can be performed and the sample sent to the lab for luminescence crystal testing.

Dual energy CT is another possibility.

Nice example,

Steve

[Diane]

Hi Steve, I had another case that was query gout. The male patient was very sore at the 1st MTPJ (medial aspect). There was definitely synovitis. The medial capsule of the MTPJ looked thickened and echogenic. When I was looking through the cineloops, I don’t know if there could be a subtle double cortex sign?
On the comparison image of the left/right toe, I placed an arrow where I thought the echogenic area may be a just capsule thickening or does that look like tophus…?

Thanks!

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[Stephen Bird]

So good,

This is a no brainer for me,

It is so much gout I can smell it here in Adelaide all the way from Perth!

Synovitis, double contour sign, classic joint to be involved, right gender, early tophus formation and crystals everywhere.

Gout, Gout, Gout !

Steve

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