Email Alert | RSS

Journal of Peking University (Health Sciences) ›› 2021, Vol. 53 ›› Issue (1): 143-149. doi: 10.19723/j.issn.1671-167X.2021.01.022

Previous Articles     Next Articles

Risk factors and diagnostic value for ultrasound-detected tendon monosodium urate crystal deposition in patients with gout

WANG Yu,DENG Xue-rong,JI Lan-lan,ZHANG Xiao-hui,GENG Yan,ZHANG Zhuo-li()   

  1. Department of Rheumatology and Immunology, Peking University First Hospital, Beijing 100034, China
  • Received:2020-09-11 Online:2021-02-18 Published:2021-02-07
  • Contact: Zhuo-li ZHANG E-mail:zhuoli.zhang@126.com
  • Supported by:
    National Natural Science Foundation of China(81771740)

RICH HTML

 15   

PDF (PC)

210

Abstract:

Objective: To evaluate frequency and patterns, risk factors of MSU (monosodium urate) crystal deposition at lower extremity tendon by ultrasonography in gout patients, and to explore diagnostic value by ultrasonography.Methods: Patients diagnosed with gout and age matched healthy controls had ultrasound scanning of both feet and knees including joints and tendons (achilles, quadriceps, and patellar tendon). Readers who scored the ultrasound scans for MSU crystal deposition were blinded to the patients’ clinical diagnoses. Clinical characteristics were compared between positive and negative crystal deposition groups by US, and risk factors of MSU deposition in tendons were analyzed. Diagnostic values of MSU deposition were evaluated by ultrasonography according with positive MSU crystal in synovial fluid or tophi by polarized microscopy.Results: Eighty patients and eighty healthy controls were included. Thity-three patients (47.5%) had tophi by physical examination. The achilles tendon was the most commonly involved tendon site 41(51.2%), followed by the quadriceps tendons 22(27.5%), and patella tendon 10(12.5%). There were no MSU deposition in healthy control group at tendon by ultrasonography. Compared with negative MSU deposition at tendon site by ultrasonography, tendon MSU positive patients had longer mean gout duration [(87.3±40.9) months vs. (7.7±2.6) months, P=0.001];higher frequency of gout flare [2(1, 2) /year vs. 1(1,1) /year, P=0.001]; higher BMI [(26.3±2.5) kg/m2vs. (23.3±2.1) kg/m2, P=0.05]. Also, the mean serum uric acid and creatinine levels were higher in tendon MSU positive group [(584.6±87.6) μmol/L vs. (460.4±96.7) μmol/L, P=0.001] and [(90.9±33.3) μmol/L vs. (70.6±40.2) μmol/L, P=0.02] separately. Logistic regression analysis showed gout duration and flare frequency were independent risk factors for MSU deposition at tendon by ultrasonography (P<0.01). Joint or tophi aspirations were performed in all the eighty gout patients, and positive MSU crystals in synovial fluid analysis by polarized microscopy were defined as the golden standard of gout diagnosis. When compared with the golden standard, the sensitivity and specificity were 94.0% and 78.0% separately for MSU deposition at tendon by ultrasonography. Conclusion: Tendon involvement at the lower extremity tendons in gout is very common. Long gout disease duration and high frequency of gout flare are both independent risk factors of tendon MSU deposition by ultrasonography. Ultrasonography had good sensitivity and specificity for detecting tendinous tophi and aggregates.

Key words: Gout, Tendon, Sodium urate monohydrate, Ultrasonography, Diagnostic value

CLC Number: 

  • R589.7

Table 1

Demographics and clinical and laboratory findings in gout patients and control group"

Items Gout Control P
n 80 80
Age/years 56.3±13.4 55.6±10.3 0.548
Male/% 90 80 0.606
Disease duration/months 71.5±48 NA
Gout flare frequency(/year) 1(1,2) NA
BMI/(kg/m2) 28.2±6.1 22.8±7.1 0.001
Serum uric acid/(μmol/L) 596.3±117.2 323.7±96.3 0.001
Serum creatinine/(μmol/L) 81.3±38.3 76.4±31.7 0.672
hsCRP/(mg/L) 12.5±3.2 3.6±1.1 0.005

Table 2

Features of MSU deposition by ultrasound in gout patients and normal control group"

Items Gout Control P
n 80 80
Double contour sign, n(%) 10 (12.5) 0/80 (0) 0.001
Tophi N, n(%) 50 (62.5) 0 (0) 0.001
Intratendinous hyperechoic
aggregates, n(%)		 26 (32.5) 0 (0) 0.001
Intratendinous tophus, n(%) 44 (55.0) 0 (0) 0.001

Table 3

Sites of tendon involvement in gout patients"

Items Achilles tendon Quadriceps Patellar tendon
Intra-tendinous tophi, n(%) 32 (40.0) 14 (17.5) 6 (7.5)
Hyperechoic aggregates, n(%) 9 (11.3) 8 (10.0) 4 (5.0)
Power Doppler signal, n(%) 3 (3.7) 10 (12.5) 4 (5.0)

Table 4

Demographic and characteristics of gout patients with MSU deposition in tendon by ultrasonography"

Items Positive MSU deposition by US Negative MSU deposition by US P
n 44 36
Age/years, x-±s 53.8±9.8 49.2±12.1 0.217
Male, n(%) 40 (91) 34 (94) 0.871
Disease duration/months, x-±s 87.3±40.9 7.7±2.6 0.001
Gout flare frequency(/year), M(P25, P75) 2 (1,2) 1 (1,1) 0.001
BMI/(kg/m2), x-±s 26.3±2.5 23.3±2.1 0.05
Serum uric acid/(μmol/L), x-±s 584.6±87.6 460.4±96.7 0.001
Serum creatinine/(μmol/L), x-±s 90.9±33.3 70.6±40.2 0.02
hsCRP/(mg/L), x-±s 13.8±4.2 12.8±3.2 0.601

Table 5

Sensitivity, specificity and diagnostic odds ratio of US at detecting MSU crystal deposits at joint or tendon level"

Items Sensitivity (95%CI) Specificity (95%CI) Diagnostic odds ratio
Tendon tophi or aggregates 0.94 (0.77-0.99) 0.78 (0.63-0.88) 4.16 (2.45-7.06)*
Tendon tophi 0.87 (0.69-0.95) 0.82 (0.67-0.90) 4.74 (2.59-8.69)*
Tendon aggregates 0.63 (0.44-0.79) 0.76 (0.62-0.86) 2.63 (1.50-4.63)*
[1] Wallace SL, Robinson H, Masi AT, et al. Preliminary criteria for the classification of the acute arthritis of primary gout[J]. Arthritis Rheum, 1977,20(3):895-900.
doi: 10.1002/art.1780200320 pmid: 856219
[2] Filippou G, Pascart T, Iagnocco A. Utility of ultrasound and dual energy CT in crystal disease diagnosis and management[J]. Curr Rheumatol Rep, 2020,22(5):15.
doi: 10.1007/s11926-020-0890-1 pmid: 32291581
[3] Gutierrez M, Schmidt WA, Thiele RG, et al. International consensus for ultrasound lesions in gout: results of Delphi process and web-reliability exercise[J]. Rheumatology(Oxford), 2015,54(10):1797-1805.
[4] 中华医学会内分泌学分会. 中国高尿酸血症与痛风诊疗指南(2019)[J]. 中华内分泌代谢杂志, 2020,36(1):1-13.
[5] Terslev L, Gutierrez M, Christensen R, et al. Assessing elementary lesions in gout by ultrasound: results of an OMERACT patient-based agreement and reliability exercise[J]. J Rheumatol, 2015,42(11):2149-2154.
doi: 10.3899/jrheum.150366 pmid: 26472419
Richette P, Doherty M, Pascual E, et al. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout[J]. Ann Rheum Dis, 2020,79(1):31-38.
[6] Neogi T, Jansen TLTA, Dalbeth N, et al. 2015 gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative[J]. Ann Rheum Dis, 2015,74(10):1789-1798.
doi: 10.1136/annrheumdis-2015-208237 pmid: 26359487
[7] Ogdie A, Taylor WJ, Neogi T, et al. Performance of ultrasound in the diagnosis of gout in a multicenter study: comparison with monosodium urate monohydrate crystal analysis as the gold standard[J]. Arthritis Rheum, 2017,69(2):429-438.
[8] Naredo E, Uson J, Jiménez-Palop M, et al. Ultrasound-detected musculoskeletal urate crystal deposition: which joints and what findings should be assessed for diagnosing gout[J]. Ann Rheum Dis, 2014,73(8):1522-1528.
doi: 10.1136/annrheumdis-2013-203487
[9] Dalbeth N, Kalluru R, Aati O, et al. Tendon involvement in the feet of patients with gout: a dual-energy CT study[J]. Ann Rheum Dis, 2013,72(9):1545-1548.
doi: 10.1136/annrheumdis-2012-202786
[10] Di Matteo A, Filippucci E, Cipolletta E, et al. The popliteal groove region: A new target for the detection of monosodium urate crystal deposits in patients with gout: an ultrasound study[J]. Joint Bone Spine, 2019,86(1):89-94.
doi: 10.1016/j.jbspin.2018.06.008 pmid: 30025961
[11] 邓雪蓉, 耿研, 张卓莉. 不同时期痛风性关节炎的超声特征比较[J]. 中华风湿病学杂志, 2016,20(1):23-27.
[12] Wang Y, Deng X, Xu Y, et al. Detection of uric acid crystal deposition by ultrasonography and dual-energy computed tomography: a cross-sectional study in patients with clinically diagnosed gout[J]. Medicine (Baltimore), 2018,97(42):e12834.
[13] Sun C, Qi X, Tian Y, et al. Risk factors for the formation of double-contour sign and tophi in gout[J]. J Orthop Surg, 2019,14(1):239.
[14] Ventura-Ríos L, Sánchez-Bringas G, Pineda C, et al. Tendon involvement in patients with gout: an ultrasound study of prevalence[J]. Clin Rheumatol, 2016,35(8):2039-2044.
doi: 10.1007/s10067-016-3309-7 pmid: 27236513
[15] Yuan Y, Liu C, Xiang X, et al. Ultrasound scans and dual energy CT identify tendons as preferred anatomical location of MSU crystal depositions in gouty joints[J]. Rheumatol Int, 2018,38(5):801-811.
doi: 10.1007/s00296-018-3994-4 pmid: 29442150
[16] Carroll M, Dalbeth N, Allen B, et al. Ultrasound characteristics of the achilles tendon in tophaceous gout: a comparison with age- and sex-matched controls[J]. J Rheumatol, 2017,44(10):1487-1492.
doi: 10.3899/jrheum.170203 pmid: 28765249
[17] Wakefield RJ, Smith K, Wakefield SM, et al. Tendon paratenon involvement in patients with gout: an under-recognized ultrasound feature of tendinous gout [J/OL]. Joint Bone Spine, 2020[2020-07-01]. http://doi.org/10.1016/j.jbspin.2020.07.001.
[18] Christiansen SN, Østergaard M, Terslev L. Ultrasonography in gout: utility in diagnosis and monitoring[J]. Clin Exp Rheumatol, 2018,36(Suppl 5):61-67.
[19] Peiteado D, Villalba A, Martín-Mola E, et al. Ultrasound sensitivity to changes in gout: a longitudinal study after two years of treatment[J]. Clin Exp Rheumatol, 2017,35(5):746-751.
pmid: 28281462
[20] Chhana A, Callon KE, Dray M, et al. Interactions between tenocytes and monosodium urate monohydrate crystals: implications for tendon involvement in gout[J]. Ann Rheum Dis, 2014,73(9):1737-1741.
doi: 10.1136/annrheumdis-2013-204657 pmid: 24709860
[21] Ray K. Tendon damage in gout: a role for MSU crystals[J]. Nat Rev Rheumatol, 2014,10(6):321.
doi: 10.1038/nrrheum.2014.65 pmid: 24752181
[22] Christiansen SN, Østergaard M, Slot O, et al. Ultrasound for the diagnosis of gout: the value of gout lesions as defined by the outcome measures in rheumatology ultrasound group[J]. Rheu-matology(Oxford), 2021,60(1):239-249.
[1] Zhe PENG,Ya-min DING,Lin PEI,Hai-hong YAO,Xue-wu ZHANG,Su-mei TANG. Clinical characteristics of crystal deposits in joints and tendons in patients with gout [J]. Journal of Peking University (Health Sciences), 2021, 53(6): 1067-1071.
[2] WANG Gui-hong,ZUO Ting,LI Ran,ZUO Zheng-cai. Effect of rebamipide on the acute gouty arthritis in rats induced by monosodium urate crystals [J]. Journal of Peking University (Health Sciences), 2021, 53(4): 716-720.
[3] XIE Yi-fan,WANG Yu,DENG Xue-rong,GENG Yan,JI Lan-lan,ZHANG Zhuo-li. Analysis of risk factors influencing the detection rate of urate crystal by dual energy computed tomography [J]. Journal of Peking University (Health Sciences), 2021, 53(2): 261-265.
[4] YANG Guang-xin,LUAN Jing-yuan,JIA Zi-chang. Radiofrequency obliteration of varicose veins of lower extremity guided by combined venography and ultrasonography [J]. Journal of Peking University (Health Sciences), 2021, 53(2): 332-336.
[5] Xiao-ran NING,Zi-qiao WANG,Shan-shan ZHANG,Xia ZHANG,Su-mei TANG,Yan-ying LIU. Application of ultrasonography scoring system in the assessment of IgG4-related sialadenitis [J]. Journal of Peking University(Health Sciences), 2019, 51(6): 1032-1035.
[6] Ning-ning LI,Li-na JI,Shuang CHAO,Ke YUAN,Hong MENG,Zhen-yu HUANG,Hua-bin ZHANG. Ultrasound screening and follow-up study of congenital anomalies of the kidney and urinary tract in neonates [J]. Journal of Peking University(Health Sciences), 2019, 51(6): 1062-1066.
[7] Peng FU,Wen CHEN,Li-gang CUI,Hui-yu GE,Shu-min WANG. Applicational value of 2017 ACR TI-RADS stratification in diagnosing thyroid nodules [J]. Journal of Peking University(Health Sciences), 2019, 51(6): 1067-1070.
[8] Yi-chong ZHANG,Jian-hai CHEN,Yu DANG,Ming YANG,Zhong-guo FU,Dian-ying ZHANG,Pei-xun ZHANG,Bao-guo JIANG. Correlation analysis between rotator cuff tear and the superior migration of humeral head [J]. Journal of Peking University(Health Sciences), 2019, 51(2): 273-276.
[9] Lan-lan JI,Yan-jie HAO,Zhuo-li ZHANG. A case of gout secondary to primary myelofibrosis [J]. Journal of Peking University(Health Sciences), 2018, 50(6): 1117-1119.
[10] CUI Chen， JIANG Jie， CHEN Wen， CUI Li-gang， WANG Jin-rui. Xanthogranulonatous pyelonephritis: report of 5 cases#br# [J]. Journal of Peking University(Health Sciences), 2018, 50(4): 743-746.
[11] ZHANG Qian-ru, WANG Yu, ZHANG Zhuo-li. Performance of the 2015 ACR/EULAR classification criteria compared with other classification criteria for diagnosis of gout in Chinese patients [J]. Journal of Peking University(Health Sciences), 2017, 49(6): 979-984.
[12] LIU Chang, CUI Li-gang, WANG Hong-lei. Renal Ewing’s sarcoma/primitive neuroectodermal tumor: a case report and literature review [J]. Journal of Peking University(Health Sciences), 2017, 49(5): 919-923.
[13] XU Ting, LI Min, TIAN Yang, SONG Jin-tao, NI Cheng, GUO Xiang-yang. Clinical evaluation of in-plane ultrasound-guided thoracic paravertebral block using laterally intercostal approach [J]. Journal of Peking University(Health Sciences), 2017, 49(1): 148-152.
[14] GENG Jiao, LI Min. Ultrasoundassisted neuraxial anesthesia in a patient with previous lumbar laminectomy and fusion: a case report [J]. Journal of Peking University(Health Sciences), 2016, 48(4): 747-750.
[15] XU Lin, CHEN Fang-min, WANG Lei, ZHANG Pei-xun, JIANG Xiao-rui. Clinical auxiliary diagnosis value of high frequency ultrasonographic measurements of the thickness of transverse carpal ligaments in carpal tunnel syndrome patients [J]. Journal of Peking University(Health Sciences), 2016, 48(2): 341-345.
Viewed
Full text


Abstract

Cited
  Shared   
  Discussed   
[1] . [J]. Journal of Peking University(Health Sciences), 2009, 41(4): 456 -458 .
[2] . [J]. Journal of Peking University(Health Sciences), 2009, 41(2): 125 -128 .
[3] . [J]. Journal of Peking University(Health Sciences), 2009, 41(2): 158 -161 .
[4] . [J]. Journal of Peking University(Health Sciences), 2009, 41(2): 217 -220 .
[5] . [J]. Journal of Peking University(Health Sciences), 2009, 41(1): 52 -55 .
[6] . [J]. Journal of Peking University(Health Sciences), 2009, 41(1): 109 -111 .
[7] . [J]. Journal of Peking University(Health Sciences), 2009, 41(3): 297 -301 .
[8] . [J]. Journal of Peking University(Health Sciences), 2009, 41(5): 505 -515 .
[9] . [J]. Journal of Peking University(Health Sciences), 2009, 41(5): 599 -601 .
[10] . [J]. Journal of Peking University(Health Sciences), 2009, 41(5): 516 -520 .
Copyright © Journal of Peking University (Health Sciences), All Rights Reserved.
Powered by Beijing Magtech Co. Ltd