I. Hotea 1, M. Magdalena Tamas 1,3, C. Pamfil 1, N. Rednic 5, T. O. Crișan 2, R. Popp 2, L. Ab Joosten 2,4, S. Rednic 1,3
1. Department of Rheumatology “Luliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania 2. Department of Medical Genetics “Luliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania 3. Department of Rheumatology Emergency County Hospital Cluj-Napoca, Romania 4. Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands 5. Department of Internal Medicine, Railway Hospital, Cluj-Napoca, Romania.
Introduction: In the course of gout patients experience episodes of inflammatory arthritis. The role of imaging techniques such as ultrasonography (US) is well established for the diagnosis and monitoring gouty arthritis. Specific features of joint involvement can be determined by using US, the double contour sign and tophus detection being the most specific ones. Signs of active disease can be present such as synovial hypertrophy, with or without power Doppler (PD) signal. Contrast enhance ultrasonography (CEUS) allows a better visualization of blood flow in small vessels, providing more information on synovial inflammation compared to PDUS. However, a role for CEUS in daily rheumatologic clinical practice has not been established yet.
Objective: To evaluate and describe joint involvement in patients with gout, using CEUS.
Methods: We included consecutive patients diagnosed with gout based on ACR/EULAR 2015 classification criteria with minimum 8 points. All patients were informed about the procedure and they signed a written informed consent form. Every patient presented at least one recent symptomatic joint not related to other condition. US examinations were performed using a Acuson S2000 machine, Siemens Healthcare. Cadence CPS Technology was used for CEUS technique. One symptomatic joint was scanned in each patient, from the dorsal aspect, to detect synovial inflammation. Synovial hypertrophy and PD signal were scored on a semiquantitative scale (0-3, each). For CEUS, the settings included a low mechanical index (0.07) and 60 seconds per cine video-clip. For each examination 2.4 ml Sonovue (Bracco, Milano, Italy) was injected in an antecubital vein in a shot bolus, washed with 10 ml saline solution. The intensity of contrast-enhancement was quantified as low, medium, high according to the area of the joint covered by contrast (< 25%, 25%-50%, > 50%).
Results: A total of 7 patients were included in the study 6 M: 1F, mean age 68±7 years, mean disease duration 7 years, 3 patients presented tophaceous form of gout. At the evaluation point, 6 of 7 patients were currently under hypouricemic treatment, 2 of them with >6 mg/dl of serum uric acid levels. Four out of 7 patients presented elevated inflammatory markers. Only one patient was evaluated during the first day of acute gout attack, before treatment; the others were having already anti-inflammatory medication prescribed for the attack. A number of 7 joints were scanned: five 1st metatarsophalangeal (MTP) joints and two Wrists. US demonstrated the presence of synovial hypertrophy in all scanned joints. Three joints expressed PD grade 1, while a grade 2 PD was seen in two joints. Contrast was present in 3 out of 5 MTP joints and in both wrists. A low intensity of contrast was observed in four joints. The only joint with a high contrast uptake was in the case of the acute attack before treatment.
Conclusion: CEUS did not prove to be more sensitive to detect inflammation compared with PD signal in gout patients. CEUS might be a useful tool to detect signs of gouty arthritis in the first hours of onset. More patients are needed to validate these preliminary results.