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Dual-Energy Computed Tomography: a Valid Tool in the Assessment of Gout?

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Dual-Energy Computed Tomography: a Valid Tool in the Assessment of Gout? PersPective Dual-energy computed tomography: a valid tool in the assessment of gout? Gout is the most common inflammatory arthropathy worldwide and the most prevalent inflammatory arthropathy in males. One of the risk factors implicated in the rising prevalence of gout is metabolic syndrome. Gout itself is an independent risk factor for cardiovascular morbidity and mortality. Current imaging modalities for gout lack specificity and sensitivity, especially with atypical presentations. Dual-energy computed tomography (DECT) is a promising new tool for imaging monosodium urate deposits with a high degree of specificity and sensitivity. DECT has the ability to detect subclinical gout, potentially allowing early detection of urate tophi in asymptomatic hyperuricemic patients. DECT could potentially serve as a primary imaging modality in the diagnosis of gout and monitoring response to urate-lowering therapy. Keywords: crystal deposition arthropathy n dual-energy computed tomography Amir Yashar Tashakkor1, n gout imaging Jimmy Tanche Wang1, David Tso1, Hyon K Choi2 & Savvas Nicolaou*1 Gout is the most common inflammatory present in gout, is an alternate independent 1Department of Radiology, Faculty of arthropathy worldwide and arises from the risk factor for stroke [6]. Lastly, gout itself has Medicine, University of British crystallization of monosodium uric acid (MSU) been recognized as an independent risk fac- Columbia, V5Z 1M9, Canada 2Section of Rheumatology & the within the joints. Currently in the USA alone, tor for cardiovascular morbidity and mortal- Clinical Epidemiology Unit, Boston more than 8 million individuals over the age ity [7]. Therefore, along with pharmacologi- University School of Medicine, 650 Albany Street, Suite 200, Boston, of 20 years are suffering from this disease [1]. cal and lifestyle changes, new techniques for MA 02118, USA Burden of disease for individuals suffering from early detection and treatment of gout will be *Author for correspondence: gout continues to expand with the prevalence in necessary in managing this rising epidemic. Division of Emergency/Trauma Imaging, Vancouver General Hospital, the USA increasing by nearly 150% in the last Many physicians rely on clinical presenta- 899 W 12th Ave., Vancouver, BC, decade [1]. Lifestyle factors, dietary choices and tion and elevated serum urate levels for the Canada Tel.: +1 604 875 4111 ext. 63659 socioeconomic parameters have been proposed diagnosis of gout; this dependence may lead Fax: +1 604 875 5195 to explain these epidemiological observations to misdiagnosis or a late diagnosis associated [email protected] [2]. Arguably, unhealthy dietary habits and with irreversible anatomical damage. Elevated sedentary lifestyle appear to be a major factor serum uric acid levels are present in 5–8% of for the rise of gout in western countries. Choi the population but only 5–20% of individuals et al. reported a 1.85 relative risk factor for inci- with hyperuricemia develop gout. Patients with dence of gout in males consuming two or more hyperuricemia may not necessarily develop gout, sugar-sweetened soft drinks per day [3]. This is and those with gout may have normal serum attributed to an increased production of uric uric acid levels, particularly during acute gout acid in the liver as well as an attenuated renal attacks [8–10]. Higher degrees and longer dura- uric acid clearance, both secondary to excessive tions of elevated urate levels can lead to greater fructose consumption. Sugar-sweetened soft severity of disease which is the impetus behind drinks represent the single largest food source lowering urate levels in the treatment of gout. of calories in the US population [4,5], and their consumption have consistently increased over Current standards of diagnosis the last decades [4]. Moreover, obesity, hyper- The gold standard for the diagnosis of gout is tension and insulin resistance, which are all aspiration of the involved joint followed by polar- associated with the metabolic syndrome, are ized light microscopy of the aspirate demonstrat- well-established independent risk factors for the ing needle-shaped negatively birefringent MSU incidence of gout. Hence, the increased pre- crystal [11]. Arthrocentesis may be technically valence of gout is partially a consequence of the challenging in a number of scenarios, including rapidly increasing incidence of these comorbid anatomically difficult-to-access joints such as conditions [2]. Moreover, hyperuricemia, often the spine and sacroiliac joint, immunodeficient part of 10.2217/IJR.11.71 © 2012 Future Medicine Ltd Int. J. Clin. Rheumatol. (2012) 7(1), 73–79 ISSN 1758-4272 73 PersPective Tashakkor, Wang, Tso, Choi & Nicolaou Dual-energy computed tomography: a valid tool in the assessment of gout? PersPective patients with inadequate fluid volumes and Conventional imaging is only capable of visu- severely inflamed joints. In addition, arthro- alizing late stages of the disease and findings centesis is painful and carries risks of infection, often correspond with the presence of irreversible hemorrhage and damage to involved tissues. tissue damage. Subclinical or untreated recur- Furthermore, samples retrieved by arthrocentesis rent gout attacks can lead to permanent joint require immediate ana lysis to conserve the tech- destruction as well as tendon and ligament rup- nique’s sensitivity and specificity, introducing ture. A cross-sectional, controlled study looked practical limitations. Many nonspecialty health- at ultrasound to detect structural changes in the care professionals mainly rely on clinical assess- joints and has shown evidence of uric acid depos- ment and the patient’s response to treatment. As its suggestive of gout in individuals with asymp- such, a noninvasive test to confirm the presence tomatic hyperuricemia [22]. Thus, early detection of MSU crystals would highly desirable. of subclinical disease could have implications in Current imaging techniques used in the patients with asymptomatic hyperuricemia given detection of gout include radiography, ultra- the high frequency in the general population. sound, computed tomography and MRI [11–13]. Unfortunately, these techniques lack the speci- DE CT: technical aspects ficity to facilitate and confirm the diagnosis of DECT, also known as spectral imaging, is a gout [12,14–16]. Classic osseous radiographic find- promising new imaging technique offering poten- ings demonstrate well-defined ‘punched out’ tial new applications in a number of clinical areas. periarticular erosions with overhanging edges, DECT has been utilized in the characterization of normal mineralization, relative preservation of urinary calculi and renal masses, myocardial per- the joint spaces and asymmetric eventual poly- fusion for ischemia, vessel/bone separation and articular distribution [11]. Such findings take virtual noncontrast imaging. Spectral imaging several years to manifest after an acute attack relies on the concept that tissues with large differ- implying these findings without urate deposits ences in atomic weights will attenuate the spectral indicate osseous changes due to remote, cur- x-ray beam by different degrees. This differential rently inactive gout [17]. The presence of urate change in attenuation of the kV spectrum allows crystals with underlying bone erosions may one to separate molecular compounds based on indicate the presence of chronic gout. their chemical composition, thereby directly visu- Ultrasound identifies tophi as echogenic nod- alizing the substrate of disease and confirming ules that cast posterior acoustic shadowing, but the presence of urate deposits in the assessment such findings are nonspecific as rheumatoid, of gout. DECT has significant advantages over heberdens, bouchard and amyloid nodules have other modalities in that it has high sensitivity similar appearances [18]. Single-energy or single- and potentially high specificity in confirming source computed tomography is a nonspecific the presence of MSU deposits [23,24]. technique for identifying urate deposits. Gouty DECT scanners are equipped with two tophus can appear as round oval opacities that x-ray tubes to allow for simultaneous acquisi- range from 150 to 200 Hounsfield unit (HU), tion at two different energy levels (e.g., 80 and and may overlap with the attenuation of calcium 140 kVp) [25]. The two-material decomposi- mineralization, making differentiation between tion algorithm applied after data acquisition is the two difficult[19] . Calcium may present over based on material-specific differences in attenu- a range of attenuations depending on density ation between the high- and low-tube-voltage and composition of the deposit. In addition, acquisition and allows for differentiation of the dual-energy computed tomography (DECT) is chemical composition of scanned tissues [26,27]. able to differentiate between tophi of different Material-specific differences depend on atomic composition, such as gout (MSU) and pseu- number, electron density and absorption of the dogout (calcium). MRI is useful in assessing x-ray beam by different degrees with each com- synovial inflammation during the early stages pound having an assigned dual-energy index of the disease [20]. However, even though MRI value. Dual-energy index values capture the may reveal additional information on the dam- difference in attenuation of materials between age produced by tophi in adjacent tissues [21], the low- and high-voltage levels. The greater the urate tophi deposits are nonspecific on
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