Rationale and Objectives
This investigation aimed to evaluate the impact on treatment regimen and clinical outcome of dual-energy computed tomography (DECT) in patients with suspected gouty arthritis.
Materials and Methods
We retrospectively analyzed electronic medical records (EMR) of 39 patients (36 male, 3 female; age range, 36–85 years) who underwent DECT of peripheral joints because of suspected gouty arthritis. We assessed the prior medical history, lab results, treatment regimen, and medications before and after DECT, and changes in subjective severity of symptoms as stated by patients in the EMR. The presence of monosodium urate (MSU) crystals in the index joint was verified with DECT.
Results
Several patients had a prior diagnosis of gout ( n = 9), hyperuricemia ( n = 6), rheumatoid arthritis ( n = 3), or psoriatic arthritis ( n = 3). Elevated uric acid blood levels were detected in 32 patients (82%) before DECT. On DECT, MSU crystals were detected in 23 patients (59%). Of the 36 cases, the current treatment regimen was modified after DECT to gout-specific therapy in 22 cases and other rheumatic diseases were targeted in 14 cases. Several medications were prescribed more frequently based after DECT compared to before DECT imaging, including steroids ( n = 20 vs. n = 12, respectively), colchicine ( n = 13 vs. n = 4, respectively), and urate-lowering medication ( n = 18 vs. n = 11, respectively). A subjective reduction of clinical symptoms during cumulative follow-up was reported by 34 patients (87.2%).
Conclusions
Both positive and negative findings of MSU crystals on DECT have a significant impact on the treatment regimen and clinical outcome of patients with suspected gouty arthritis and facilitate differentiation from other rheumatic diseases.
Introduction
Gout is a medical condition characterized by severe pain attacks in joints usually caused by crystal arthropathy because of metabolic disorders. It is one of the most common arthropathies and is presently estimated to affect 1–2% of the adult population . A gout-specific therapy differs significantly from therapeutic regimens of other rheumatic or degenerative joint diseases . Therefore, an early and accurate diagnosis of gout is crucial for targeted treatment and rapid alleviation of symptoms.
The official guidelines of the European League Against Rheumatism state that synovial fluid aspiration is the present gold standard to establish the diagnosis . Nevertheless, this technique is invasive and may be difficult to perform in small joints, although it is considered the only method to definitely confirm the presence of monosodium urate (MSU) crystals and verify gout .
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Materials and Methods
Study Design
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Medical Records
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DECT Imaging Protocol and Evaluation
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Results
Study Population and DECT Results
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TABLE 1
Patient Characteristics and Medical History
Parameter Patients Known gout 9 (23.1%) Known hyperuricemia 6 (15.4%) Known rheumatoid arthritis 3 (7.7%) Known psoriatic arthropathy 3 (7.7%) Known spondyloarthritis 1 (2.6%) Elevated uric acid 33 (84.6%)
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Patients’ Medical History and Findings on DECT
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Imaging and Clinical Presentation of Index Joints
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Therapy Regimens
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TABLE 2
Treatment Regimens
Treatment Before DECT (Patients) MSU Crystal Positive (Patients) MSU Crystal Negative (Patients) After DECT (Patients) MSU Crystal Positive (Patients) MSU Crystal Negative (Patients) Corticosteroids 12 (30.8%) 7 5 20 (51.3%) 12 8 Colchicine 4 (10.3%) 3 1 13 (33.3%) 11 2 Urate-lowering medication 11 (28.2%) 8 3 18 (46.2%) 14 4 NSAIDs 16 (41.0%) 10 6 16 (41.0%) 12 4 Metamizole 4 (10.3%) 2 2 11 (28.2%) 5 6 Methotrexate 3 (7.7%) 1 2 3 (7.7%) 0 3 Biological agent 4 (10.3%) 2 2 4 (10.3%) 1 3 Opioid analgesic 2 (8.7%) 1 1 4 (10.3%) 3 1 Antibiotic therapy 1 (2.6%) 1 0 1 (2.6%) 0 1 Nonmedical treatment 0 0 0 4 (10.3%) 2 2
DECT, dual-energy computed tomography; MSU, monosodium urate; NSAIDs, nonsteroidal anti-inflammatory drugs.
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TABLE 3
Therapy Modification after DECT
Parameter All (Patients) MSU Crystals Positive (Patients) MSU Crystals Negative (Patients) Change in therapy after DECT 36 (92.3%) 21 (58.3%) 15 (41.7%) Change from other to gout-specific therapy 14 (35.9%) 11 (78.6%) 3 (21.4%) Maintained gout-specific therapy 8 (20.51%) 6 (75.0%) 2 (25.0%) Change from gout-specific to other therapy 2 (5.1%) 1 (50.0%) 1 (50.0%) Modified other therapy 12 (30.8%) 3 (25.0%) 9 (75.0%)
DECT, dual-energy computed tomography; MSU, monosodium urate.
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Outcome
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TABLE 4
Outcome/Follow-up
Follow-up Date Follow-up Data Available (Patients) Stated Improved Health Condition (Patients) Stated Stable or Worse Health Condition (Patients) At any follow-up date 39 (100%) 34 (87.2%) 5 (12.8%) At day of discharge 21 (53.8%) 19 (90.5%) 2 (9.5%) At <3 months follow-up 10 (25.6%) 8 (80%) 2 (20%) At >3 months follow-up 18 (46.2%) 11 (61.1%) 7 (38.9%)
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Discussion
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