Case Communications

Sonographic Features of a Tophaceous Nodule

Alexandra Balbir-Gurman MD1, Abraham M. Nahir MD PhD1, Yolanda Braun-Moscovici MD1 and Michal Soudack MD2

Departments of 1Rheumatology and 2Diagnostic Imaging, Rambam Medical Center, Haifa, Israel

Key words: , tophi, ultrasound IMAJ 2005;7:746–747

Subcutaneous nodules with prominent above the second and third metacarpo- geneous material [Figure A], which was inflammatory features are a diagnostic phalangeal joints was extremely painful, hyperemic on power Doppler [Figure B]. challenge [1]. The differential diagnosis warm, swollen, and hyperemic. There was There was no fluid collection. The dif- includes ganglion, cyst, space-occupying a mild fluctuation on palpation. ferential diagnosis of the sonographic lesion, tenosynovitis, rheumatoid nodule, Laboratory investigation revealed an findings included hypertrophied synovia infection, and tophaceous nodule. An elevated sedimentation rate of 75 mm/ or tophaceous deposits and excluded imaging technique that could specifically hour, elevated white blood cell count abscess formation. Ultrasound-guided demonstrate monosodium urate deposits (12,000x103/ml) with mild left shift (neu- needle aspiration of the lesion yielded a within tissues can be extremely helpful, trophils 88%), normal levels of serum cre- cream-yellow sterile discharge with a very especially in patients presenting with atinine and glucose. Serum levels of uric high count of leukocytes, mostly neutro- swelling of soft tissues or nodules of acid were elevated: unknown causes. On Doppler ultrasonog- 10.2 mg/dl. X-ray of A raphy, the tophi appear as attenuating the hand showed hypoechogenic structures with shadowing typical osteoarthritic and hypervascularity representing inflam- changes in distal mation, surrounded by hyperechogenic and proximal inter- tissue [2]. These findings cannot be con- phalangeal joints, sidered specific for gout as they resemble and soft tissue rheumatoid nodules, but are different swelling above the from those of abscess or fluid collection second and third [2]. We describe a patient who developed metacarpophalan- a painful, red, warm swelling above the geal joints without second and third metacarpophalangeal signs of osteomy- joints. The Doppler ultrasound (Sonosite- elytis. 99mTc bone Titan, Linear transducer L38 with a fre- scan showed diffuse quency 5–10 broad band MHz) examina- hyperemia above tion allowed us to differentiate the lesion the right metacar- from an abscess or joint effusion, and to pus, and increased suggest gouty tophi. uptake largely lim- ited to the second B Patient Description and third metacar- A 75 year old man was hospitalized with pophalangeal joints severe pain and swelling on the back consistent with joint of his right hand that appeared several inflammation and/or days previously. His medical history was infection. Doppler uneventful, except for a mild memory ultrasound examina- disorder. He denied a history of kidney tion of the dorsal stones or renal colic, joint pain, and aspect of the hand the use of drugs including diuretics. He revealed localized was afebrile. Vital signs and the general soft tissue swell- physical examination were unremarkable. ing and thickened Joint examination disclosed deformities extensor tendons [A] Transverse ultrasound scan of dorsal aspect of right hand, demonstrating extensor tendons (asterisk) surrounded by a thick of distal and proximal interphalangeal surrounded by bulky hypoechoic rim (arrows). joints, typical of . The area hypoechoic hetero- [B] Power Doppler showing increased vascularization.

746 A. Balbir-Gurman et al. • Vol 7 • November 2005 Case Communications phils, and typical intra-leukocyte monoso- to differentiate the tophaceous inflamed Acknowledgment. The authors thank Mrs. dium urate crystal inclusions. Polarizing nodule from abscess and may also be M. Perlmutter for her help in the prepara- microscopy revealed multiple negative performed by mobile ultrasound units at tion of this paper. birefringence needle-shaped crystals. the patient’s bedside. Doppler ultraso- Treatment with a short course of in- nography cannot replace the aspiration References domethacine (75 mg/day) and colchicine of the suspected infected lesion, but 1. Nalbant S, Corominas H, Hsu B, Chen (1.5 mg/day) was started and rapid clini- performance of the aspiration guided by LX, Schumacher HR, Kitumnuaypong cal improvement was achieved. A week Doppler is much easier and precise [3]. T. Ultrasonography for assessment of later, with resolution of inflammatory As tophaceous gout and infection may subcutaneous nodules. J Rheumatol 2003; signs, indomethacine was discontinued appear simultaneously, aspiration of the 30:1191–5. 2. Gerster JC, Landry M, Dyfresne L, Meu- and treatment with allopurinol (200 mg/ lesion is mandatory, both to exclude in- wly JY. Imaging of tophaceous gout: day) was begun. Repeat Doppler ultraso- fection and to demonstrate crystal mono- computed tomography provides specific nography 2 months following combined sodium urate [4]. images compared with magnetic reso- colchicine and allopurinol treatment Our report emphasizes the pos- nance imaging and ultrasonography. Ann showed significant resolution of soft tis- sible role of Doppler ultrasonography Rheum Dis 2002;61:52–4. 3. Balint PV, Kane D, Hunter JA, Mcinnes sue swelling and hypoechoic areas. as a quick and sensitive supplementary IB, Field M, Sturrock RD. A comparison diagnostic tool in suspected gouty to- of ultrasound-guided with conventional Comment phi inflammation. It is a non-invasive guided joint aspiration in While gout is a common disease, the bedside imaging tool that is extremely practice – a pilot study. J Rheumatol 2002; diagnosis of tophi is sometimes missed, helpful in cases of suspected soft tis- 29:2209–13. 4. Schuind FA, Remmelink M, Pasteels JL. mostly in atypical presentation of gouty sue abscess, in detection of articular Co-existent gout and septic at arthritis [1]. We describe a case of un- and periarticular structure involvement the wrist: a case report. Hand Surg 2003; usual tophaceous gout arthritis that (tendons and sheaths, gouty tophi, 8(1):107–9. presented as a very inflamed soft tissue rheumatoid nodules), in differentiation mass on the dorsal surface of the hand of synovial proliferation or fluid collec- Correspondence: Dr. A. Balbir-Gurman, without evidence of tophi formation in tion, in assessment of the severity and Dept. of Rheumatology, Rambam Medical the typical sites (elbows, first metatar- dynamics of the inflammatory process, Center, P.O. Box 9602, Haifa 31096, Israel. sophalangeal joints, ears). The clinical and in guided-needle aspiration of sus- Phone: (972-4) 854-2268 features suggested infection and pus for- pected lesions in everyday rheumatology Fax: (972-4) 854-2985 mation. Doppler ultrasound allowed us practice. email: [email protected]

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Capsule Primate-to-human retroviral transmission in Asia Jones-Engel et al. describe the first reported transmission from the blood of the same person. Cloning and sequenc- to a human of simian foamy virus (SFV) from a free-rang- ing of PCR products confirmed the virus’s close phylogenet- ing population of non-human primates in Asia. The trans- ic relationship to SFV isolated from macaques at the same mission of an exogenous retrovirus, SFV, from macaques temple. This study raises concerns that persons who work (Macaca fascicularis) to a human at a monkey temple in Bali, at or live around monkey temples are at risk for infection Indonesia, was investigated with molecular and serologic with SFV. techniques. Antibodies to SFV were detected by Western blotting of serum from 1 of 82 humans tested. SFV DNA Emerg Infect Dis 2005;11:1028 was detected by nested polymerase chain reaction (PCR) Eitan Israeli

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