G Model
ARTICLE IN PRESS
BONSOI-4003; No. of Pages 1
Joint Bone Spine xxx (2014) xxx–xxx
Available online at www.sciencedirect.com
Image in rheumatology
Tophi in anterior chest wall Cheng-Hsun Lu , Song-Chou Hsieh , Ko-Jen Li ∗ Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, National Taiwan University Hospital, Postal address: no.7, Chung Shan S. Road, Taipei 100, Taiwan, ROC
Fig. 1.
1. Introduction A 70-year-old man, who was bedridden following a cerebrovascular accident, presented with painful swelling of bilateral sternoclavicular joints, as well as first and second costosternal joints. Chest computed tomography showed inflammation and bone erosions at the anterior chest wall (Fig. 1, arrows), suspected synovitis, acne, pustulosis, hyperostosis, osteitis syndrome (SAPHO) by a radiologist. However, neither prominent hyperostosis nor bone hypertrophy was found. He had a history of gout as well as tophi at bilateral metatarsophalangeal and right elbow joints. The serum uric acid was slightly elevated (6.6 mg/dL) with a creatinine clearance of 54.5 mL/min. An ultrasonography of his sternoclavicular and costosternal joints found active synovitis with multiple hyperechoic foci in the joints (Fig. 2), resulting in “snowstorm appearance”, which might represent microtophi and raised the suspicion of gout. Needle aspiration yielded chalky material, and polarized light microscopy revealed numerous monosodium
Fig. 2.
urate crystals. Tophus in the anterior chest wall was confirmed. Tenderness and swelling of the joints were improved by nonsteroid anti-inflammatory drug and colchicine. Gout rarely attacks the anterior chest wall. Ultrasonography can detect synovitis, bone erosions, as well as tophaceous deposits in soft tissues, joints, and cartilage. In patients susceptible to gout, characteristic ultrasonographic findings serve as a useful diagnostic tool [1,2]. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Ottaviani S, Bardin T, Richette P. Usefulness of ultrasonography for gout. Joint Bone Spine 2012;79:441–5. [2] Dalbeth N, Doyle AJ. Imaging of gout: an overview. Best Pract Res Clin Rheumatol 2012;26:823–38.
∗ Corresponding author. Tel.: +886 22 31 23 456x65909; fax: +886 22 32 19 837. E-mail address: [email protected] (K.-J. Li). doi:10.1016/j.jbspin.2014.03.001 1297-319X/© 2014 Published by Elsevier Masson SAS on behalf of the Société Française de Rhumatologie.
Please cite this article in press as: Lu C-H, et al. Tophi in anterior chest wall. Joint Bone Spine (2014), doi:10.1016/j.jbspin.2014.03.001
ARTICLE IN PRESS
BONSOI-4003; No. of Pages 1
Joint Bone Spine xxx (2014) xxx–xxx
Available online at www.sciencedirect.com
Image in rheumatology
Tophi in anterior chest wall Cheng-Hsun Lu , Song-Chou Hsieh , Ko-Jen Li ∗ Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, National Taiwan University Hospital, Postal address: no.7, Chung Shan S. Road, Taipei 100, Taiwan, ROC
Fig. 1.
1. Introduction A 70-year-old man, who was bedridden following a cerebrovascular accident, presented with painful swelling of bilateral sternoclavicular joints, as well as first and second costosternal joints. Chest computed tomography showed inflammation and bone erosions at the anterior chest wall (Fig. 1, arrows), suspected synovitis, acne, pustulosis, hyperostosis, osteitis syndrome (SAPHO) by a radiologist. However, neither prominent hyperostosis nor bone hypertrophy was found. He had a history of gout as well as tophi at bilateral metatarsophalangeal and right elbow joints. The serum uric acid was slightly elevated (6.6 mg/dL) with a creatinine clearance of 54.5 mL/min. An ultrasonography of his sternoclavicular and costosternal joints found active synovitis with multiple hyperechoic foci in the joints (Fig. 2), resulting in “snowstorm appearance”, which might represent microtophi and raised the suspicion of gout. Needle aspiration yielded chalky material, and polarized light microscopy revealed numerous monosodium
Fig. 2.
urate crystals. Tophus in the anterior chest wall was confirmed. Tenderness and swelling of the joints were improved by nonsteroid anti-inflammatory drug and colchicine. Gout rarely attacks the anterior chest wall. Ultrasonography can detect synovitis, bone erosions, as well as tophaceous deposits in soft tissues, joints, and cartilage. In patients susceptible to gout, characteristic ultrasonographic findings serve as a useful diagnostic tool [1,2]. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Ottaviani S, Bardin T, Richette P. Usefulness of ultrasonography for gout. Joint Bone Spine 2012;79:441–5. [2] Dalbeth N, Doyle AJ. Imaging of gout: an overview. Best Pract Res Clin Rheumatol 2012;26:823–38.
∗ Corresponding author. Tel.: +886 22 31 23 456x65909; fax: +886 22 32 19 837. E-mail address: [email protected] (K.-J. Li). doi:10.1016/j.jbspin.2014.03.001 1297-319X/© 2014 Published by Elsevier Masson SAS on behalf of the Société Française de Rhumatologie.
Please cite this article in press as: Lu C-H, et al. Tophi in anterior chest wall. Joint Bone Spine (2014), doi:10.1016/j.jbspin.2014.03.001
