Rheumatology International

, Volume 34, Issue 6, pp 763–771 | Cite as

Systemic staging for urate crystal deposits with dual-energy CT and ultrasound in patients with suspected gout

  • Alexander Huppertz
  • Kay-Geert A. Hermann
  • Torsten Diekhoff
  • Moritz Wagner
  • Bernd Hamm
  • Wolfgang A. Schmidt
Original Article


Objective of the study is to compare the diagnostic accuracy for detecting monosodium urate crystal deposits between dual-energy CT (DECT) and ultrasound (US). Sixty consecutive patients (49 men, mean age 62 years) with clinically suspected gout were included in this case–control study. DECT and US of feet, knees, hands and elbows were performed in all patients. Polarisation microscopy of synovial fluid or a score incorporating serum uric acid level, first MTP joint involvement, gender, previous patient-reported arthritis attack, cardiovascular diseases, joint redness and onset within 1 day was used as standard of reference. Standard of reference classified 39 patients as gout positive. Sixteen patients had gout and a concomitant rheumatic disease. Sensitivities for diagnosis of gout disease were 84.6 % (33/39) for DECT and 100 % (39/39) for US. Specificities were 85.7 % (18/21) for DECT and 76.2 % (16/21) for US. Positive and negative predictive values were 91.7 % (33/36) and 75.0 % (18/24) for DECT, 88.6 % (39/44) and 100 % (16/16) for US, respectively. Urate crystals were detected most frequently in MTP1 joints (DECT 20/78, US 58/78), any other toe joints (DECT 25/78, US 62/78) and knees (DECT 41/78, US 31/78). The volumetry of DECT computed a mean urate crystal deposit load of 2.1 cm3 (SD 9.6 cm3). A mean effective dose of ≤0.5 mSv was estimated. DECT is more specific for the diagnosis of gout than US. However, it fails to detect small urate crystal deposits. It might be particularly useful for patients with ambivalent findings, concomitant rheumatic diseases and with non-conclusive joint aspiration.


Gout Crystal deposition arthropathy Dual-energy computed tomography Ultrasonography Polarisation microscopy 



The authors especially thank Carina Schuecke for the CT data acquisition and Carsten Schwenke (SCOSSiS Statistical Consulting) for his assistance in the statistical evaluation.

Conflict of interest

Alexander Huppertz is a full-time paid employee of Siemens AG since June 1, 2004. His function is Associate Director of the Imaging Science Institute Charité. The Institute is a scientific cooperation between the Charité, University Hospitals of Berlin, Germany and Siemens Healthcare in form of a private–public partnership (PPP). Wolfgang A Schmidt received research grants from Esaote SpA and General Electrics. All other authors have no competing interests to declare with respect to this study.


  1. 1.
    Crittenden DB, Pillinger MH (2013) New therapies for gout. Annu Rev Med 64:325–337PubMedCrossRefGoogle Scholar
  2. 2.
    Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T et al (2012) American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken) 64:1431–1446CrossRefGoogle Scholar
  3. 3.
    Feig DI, Kang DH, Johnson RJ (2008) Uric acid and cardiovascular risk. N Engl J Med 359:1811–1821PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Kuo CF, See LC, Luo SF, Ko YS, Lin YS, Hwang JS et al (2010) Gout: an independent risk factor for all-cause and cardiovascular mortality. Rheumatology (Oxford) 49:141–146CrossRefGoogle Scholar
  5. 5.
    Owens D, Whelan B, McCarthy G (2008) A survey of the management of gout in primary care. Ir Med J 101:147–149PubMedGoogle Scholar
  6. 6.
    McQueen FM, Doyle A, Dalbeth N (2011) Imaging in gout—what can we learn from MRI, CT, DECT and US? Arthritis Res Ther 13:246PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Nicolaou S, Liang T, Murphy DT, Korzan JR, Ouellette H, Munk P (2012) Dual-energy CT: a promising new technique for assessment of the musculoskeletal system. AJR Am J Roentgenol 199(Suppl 5):S78–S86PubMedCrossRefGoogle Scholar
  8. 8.
    Glazebrook KN, Guimarães LS, Murthy NS, Black DF, Bongartz T, Manek NJ et al (2011) Identification of intraarticular and periarticular uric acid crystals with dual-energy CT: initial evaluation. Radiology 261:516–524PubMedCrossRefGoogle Scholar
  9. 9.
    Desai MA, Peterson JJ, Garner HW, Kransdorf MJ (2011) Clinical utility of dual-energy CT for evaluation of tophaceous gout. Radiographics 31:1365–1375PubMedCrossRefGoogle Scholar
  10. 10.
    Choi HK, Burns LC, Shojania K, Koenig N, Reid G, Abufayyah M et al (2012) Dual energy CT in gout: a prospective validation study. Ann Rheum Dis 71:1466–1471PubMedCrossRefGoogle Scholar
  11. 11.
    Gruber M, Bodner G, Rath E, Supp G, Weber M, Schueller-Weidekamm C (2014) Dual-energy computed tomography compared with ultrasound in the diagnosis of gout. Rheumatology (Oxford) 53:173–179CrossRefGoogle Scholar
  12. 12.
    Stamm G, Nagel HD (2002) CT-expo—a novel program for dose evaluation in CT. Fortschr Röntgenstr 174:1570–1576CrossRefGoogle Scholar
  13. 13.
    Janssens HJ, Fransen J, van de Lisdonk EH, van Riel PL, van Weel C, Janssen M (2010) A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med 170:1120–1126PubMedCrossRefGoogle Scholar
  14. 14.
    Thiele RG, Schlesinger N (2007) Diagnosis of gout by ultrasound. Rheumatology (Oxford) 46:1116–1121CrossRefGoogle Scholar
  15. 15.
    Grassi W, Meenagh G, Pascual E, Filippucci E (2006) “Crystal clear”-sonographic assessment of gout and calcium pyrophosphate deposition disease. Semin Arthritis Rheum 36:197–202PubMedCrossRefGoogle Scholar
  16. 16.
    Choi HK, Al-Arfaj AM, Eftekhari A, Munk PL, Shojania K, Reid G et al (2009) Dual energy computed tomography in tophaceous gout. Ann Rheum Dis 68:1609–1612PubMedCrossRefGoogle Scholar
  17. 17.
    Dalbeth N, Schauer C, Macdonald P, Perez-Ruiz F, Schumacher HR, Hamburger S et al (2011) Methods of tophus assessment in clinical trials of chronic gout: a systematic literature review and pictorial reference guide. Ann Rheum Dis 70:597–604PubMedCrossRefGoogle Scholar
  18. 18.
    McQueen FM, Reeves Q, Dalbeth N (2013) New insights into an old disease: advanced imaging in the diagnosis and management of gout. Postgrad Med J 89:87–93PubMedCrossRefGoogle Scholar
  19. 19.
    Dalbeth N, Kalluru R, Aati O, Horne A, Doyle AJ, McQueen FM (2013) Tendon involvement in the feet of patients with gout: a dual-energy CT study. Ann Rheum Dis 72:1545–1548PubMedCrossRefGoogle Scholar
  20. 20.
    Swan A, Amer H, Dieppe P (2002) The value of synovial fluid assays in the diagnosis of joint disease: a literature survey. Ann Rheum Dis 61:493–498PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Manger B, Lell M, Wacker J, Schett G, Rech J (2012) Detection of periarticular urate deposits with dual energy CT in patients with acute gouty arthritis. Ann Rheum Dis 71:470–472PubMedCrossRefGoogle Scholar
  22. 22.
    Mathieu S, Pereira B, Couderc M, Soubrier M (2013) Usefulness of ultrasonography in the diagnosis of gout: a meta-analysis. Ann Rheum Dis 72:e23PubMedCrossRefGoogle Scholar
  23. 23.
    Dalbeth N, Doyle A, McQueen FM (2012) Imaging in gout: insights into the pathological features of disease. Curr Opin Rheumatol 24:132–138PubMedGoogle Scholar
  24. 24.
    Chowalloor PV, Keen HI (2013) A systematic review of ultrasonography in gout and asymptomatic hyperuricaemia. Ann Rheum Dis 72:638–645PubMedCrossRefGoogle Scholar
  25. 25.
    Wright SA, Filippucci E, McVeigh C, Grey A, McCarron M, Grassi W et al (2007) High-resolution ultrasonography of the first metatarsal phalangeal joint in gout: a controlled study. Ann Rheum Dis 66:859–864PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Filippucci E, Riveros MG, Georgescu D, Salaffi F, Grassi W (2009) Hyaline cartilage involvement in patients with gout and calcium pyrophosphate deposition disease. An ultrasound study. Osteoarthr Cartil 17:178–181PubMedCrossRefGoogle Scholar
  27. 27.
    Peiteado D, De Miguel E, Villalba A, Ordóñez MC, Castillo C, Martín-Mola E (2012) Value of a short four-joint ultrasound test for gout diagnosis: a pilot study. Clin Exp Rheumatol 30:830–837PubMedGoogle Scholar
  28. 28.
    Ottaviani S, Richette P, Allard A, Ora J, Bardin T (2012) Ultrasonography in gout: a case–control study. Clin Exp Rheumatol 30:499–504PubMedGoogle Scholar
  29. 29.
    Naredo E, Uson J, Jiménez-Palop M, Martínez A, Vicente E, Brito E et al (2013) Ultrasound-detected musculoskeletal urate crystal deposition: which joints and what findings should be assessed for diagnosing gout? Ann Rheum Dis 2013 May 14 (Epub ahead of print)Google Scholar
  30. 30.
    Jabakumar A, Crowson CS, Udayakumar PD, Matteson EL (2012) Co-existence of gout in rheumatoid arthritis: it does happen! A population based study. Arthritis Rheum 64(Suppl):S58Google Scholar
  31. 31.
    Perez-Ruiz F, Herrero-Beites AM (2012) Prevalence of non-gout arthritis in patients with gout: Not as sparing as previously thought. Arthritis Rheum 64(Suppl):S63Google Scholar
  32. 32.
    McQueen FM, Doyle A, Reeves Q, Gao A, Tsai A, Gamble GD et al (2014) Bone erosions in patients with chronic gouty arthropathy are associated with tophi but not bone oedema or synovitis: new insights from a 3 T MRI study. Rheumatology (Oxford) 53:95–103CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Alexander Huppertz
    • 1
    • 2
  • Kay-Geert A. Hermann
    • 1
  • Torsten Diekhoff
    • 1
  • Moritz Wagner
    • 1
  • Bernd Hamm
    • 1
    • 2
  • Wolfgang A. Schmidt
    • 3
  1. 1.Department of RadiologyCharité – University HospitalsBerlinGermany
  2. 2.Imaging Science Institute CharitéBerlinGermany
  3. 3.Medical Center of RheumatologyImmanuel Krankenhaus Berlin-BuchBerlinGermany

Personalised recommendations