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Table 1. Clinical Findings in Seven Patients with Acute Gouty Arthritis Age(y) Laboratory Findings / Involved joint Symptom Gout history Uric acid WBC ESR CRP Synovial culture Sex (mg/dl) (/mm 3 ) (mm/hr) (mg/dl) 65/M Knee Pain, Swelling Great toe (8 yr) () 30/M Knee Pain, Swelling () N () 45/M Ankle Pain, Swelling Great toe (10 yr) () 59/F Knee Pain, Swelling () N N () 24/M Knee Pain, Swelling () N () 34/M Knee Pain, Swelling () N () 27/M Knee Pain, Swelling () () Note. Dash () indicates absent; =elevated; N=normal. Table 2. MR Imaging Findings in Seven Patients with Acute Gouty Arthritis Age(y) Imaging Findings Involved / Joint Bone Marrow Synovial Soft tissue T2 low joint Other findings Sex effusion erosion edema thickening changes signal foci 65/M Knee (+) () () (+) Edema (+) (+) () Abscess () 30/M Knee (+) () () (+) Edema (+) () () Abscess () 45/M Ankle (+) () () Thick irregular Edema (+) (+) () enhancement Abscess () 59/F Knee (+) () () Thick irregular Edema (+) (+) Osteoarthritis enhancement Abscess () 24/M Knee (+) () () Thick irregular Edema (+) (+) OCD enhancement Abscess () Meniscal tear 34/M Knee (+) () () Thick irregular Edema (+) (+) () enhancement Abscess () 27/M Knee (+) () (+) Thick irregular Edema (+) () () enhancement Abscess () Note. Dash () indicates absent; plus sign(+) indicates present; OCD=Osteochondritis dissecans 166
대한영상의학회지 2006;55:165-171 른 비후 혹은 불규칙한 결절형 비후로 구분하였다(12). 연부 조직 변화는 연부조직 부종이나 연부조직 농양 형성 유무를 분 석하였다. 임상기록을 통해 환자의 연령과 성별, 내원시 주소, 병력, 그리고 검사실 소견을 알아보았다. 검사실 소견은 혈중 요산치, 백혈구 수, 적혈구침강속도(erythrocyte sedimentation rate, ESR), C-반응단백(C-reactive protein, CRP) 증가 여 부, 활액 배양 결과를 알아보았다. 결 과 연구 대상 환자 7명의 임상 소견은 Table 1에 요약하였다. 남자가 6명, 여자가 1명이며, 나이는 24세부터 65세까지로 평 균연령은 41세였다. 모든 예에서 내원 시 급성 발병의 관절통 및 압통, 종창, 발적을 보였으며 콜히친 치료에 빠른 반응을 보 였다. 모든 환자에서 발열은 없었다. 2예에서 무지의 중족지관 A B D E 절을 침범하는 통풍을 진단받은 병력이 있었다. 1예를 제외한 모든 환자에서 혈중 요산 농도는 증가해 있었다. 적혈구침강속 도 증가, C-반응단백 증가를 보였으며 3예에서 경한 백혈구 수 증가를 보였다. 모든 환자에서 활액 배양에서 균의 배양은 없었으며 그람 염색에 음성이었다. 연구 대상 환자 7명의 MRI 소견은 Table 2에 요약하였다. 침범된 관절은 슬관절이 6예, 족관절이 1예 이었다. 슬관절을 침범한 모든 환자에서 관절액은 상부슬개와, 중앙부, 후대퇴함 요, 슬와하함요 부위에 많은 양의 관절액 증가를 보였으며(Fig. 1) 족관절을 침범한 1예에서도 관절액 증가를 보였다(Fig. 2). 조영증강영상을 시행한 5예 모두에서 불규칙한 결절형태의 활 액막 비후를 보였다(Fig. 1, 2). 모든 예에서 연골하 골미란은 없었으나 1예에서 대퇴골의 내측관절융기에 골수부종이 있었 다. 모든 예에서 연부조직 부종이 있었으나 연부조직 농양 형 성은 없었다. 그리고 5예에서 T2 강조영상에서 관절액내에 저 C Fig. 1. A 34-year-old man with acute gouty arthritis. A, B. Sagittal T1-weighted spin-echo MR image (A) (TR/TE, 600/15) and corresponding sagittal T2-weighted spin-echo MR image (B) (2300/90) show a large amount of joint effusion in the suprapatellar pouch, central portion, posterior femoral recess, and subpopliteal recess. Multiple low signal foci in the suprapatellar pouch are seen (arrows). C, D. Gadolinium-enhanced sagittal (C) and fat-saturation axial (D) T1-weighted spin-echo MR images show thick irregular synovial enhancement in the suprapatellar pouch, central portion, posterior femoral recess and subpopliteal recess (arrows). E. An arthroscopic photograph shows innumerable intraarticular small, whitish urate crystals on the surface of femoral condyle. 167
이경규 외: 급성 통풍성 관절염의 MR 소견 신호강도의 다발성 물질들이 관찰되었다(Fig. 1, 2). 고 찰 통풍은 임상경과에 따라 무증상성 고요산혈증, 급성 통풍성 관절염, 관해기 통풍, 만성 결절성 통풍의 4단계로 나눈다(8). 급성 통풍성 관절염은 항상 단일관절을 침범하며 초기에는 무 지의 중족지관절을 침범하여 급성 염증반응을 유발하고, 종창, 발적, 압통을 일으키며 재발성으로 만성이 되면 차츰 족관절, 슬관절, 수지관절, 완관절, 주관절 및 척추를 침범한다(1, 57). 가장 많이 침범하는 무지의 중족지관절 이외의 관절을 침 범한 경우에는 급성 통풍성 관절염과 패혈성 관절염의 임상 소 견 및 검사실 소견이 비슷하여 감별이 어려울 수 있다(2, 3). 통풍은 어느 연령에서 발생할 수 있으나 보통 사춘기부터 고 요산혈증이 시작되어 30-40대 이후부터 임상증상이 나타난 다. 임상 증상은 급성 통풍시 몇 시간 내 발생하는 급성 발병 의 관절통, 압통, 종창 및 발적 등을 보이며 특별한 치료가 없 어도2주 이내에 호전된다. 검사실 소견상 백혈구, 적혈구침강 속도 및 C-반응단백 등이 증가하여 감염과 비슷한 소견을 보 인다(2). 저자들은 모든 환자에서 임상소견 및 검사실 소견은 이전 보고와 비슷하였으며 일반 염증 또는 감염질환과 감별을 요하였다. 혈중 요산 농도는 남자는7 mg/dl 이상, 여자는 6 mg/dl 이상이면 고요산혈증으로 진단하고 있으며 통풍성 관 절염의 급성기에는 요산이 정상범위에 있을 수 있다(2). 저자 Fig. 2. A 45-year-old woman with acute gouty arthritis. A, B. Sagittal T1-weighted spin-echo MR image (A) (TR/TE, 450/10) and corresponding sagittal T2-weighted, fatsaturation fast spin-echo MR image (B) (4000/62) show a large amount of joint effusion in the ankle joint. C. Axial T2-weighted fast spin-echo MR image (4000/62) obtained with fat saturation at the level of talus shows a large amount of joint effusion with multiple low signal foci (arrows). D. Gadolinium-enhanced axial T1weighted spin-echo MR image (600/12) obtained with fat saturation shows thick irregular synovial enhancement (arrow). A B C D 168
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6. Duprez TP, Malghem J, Vande Berg BC, Noel HM, Munting EA, Maldague BE. Gout in the cervical spine: MR pattern mimicking diskovertebral infection. AJNR Am J Neuroradiol 1996;17:151-153 7. Barrett K, Miller ML, Wilson JT. Tophaceous gout of the spine mimicking epidural infection: case report and review of the literature. Neurosurgery 2001;48:1170-1172 8. Chen CK, Yeh LR, Pan HB, Yang CF, Lu YC, Wang JS, et al. Intraarticular gouty tophi of the knee: CT and MR imaging in 12 pa- tients. Skeletal Radiol 1999;28:75-80 9. Chen CK, Chung CB, Yeh L, Pan HB, Yang CF, Lai PH, et al. Carpal tunnel syndrome caused by tophaceous gout: CT and MR imaging in 20 patients. AJR Am J Roentgenol 2000;175:655-659 10. Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu TF. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 1977;20:895-900 11. McQueen FM, Stewart N, Crabbe J, Robinson E, Yeoman S, Tan PL, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals progression of erosions despite clinical improvement. Ann Rheum Dis 1999;58:156-163 12. Stewart NR, McQueen FM, Crabbe JP. Magnetic resonance imaging of the wrist in early rheumatoid arthritis: a pictorial essay. Australas Radiol 2001;45:268-273 13. Schweitzer ME, Falk A, Pathria M, Brahme S, Hodler J, Resnick D. MR imaging of the knee: can changes in the intracapsular fat pads be used as a sign of synovial proliferation in the presence of an effusion? AJR Am J Roentgenol 1993;160:823-826 14. Konig H, Sieper J, Wolf KJ. Rheumatoid arthritis: evaluation of hypervascular and fibrous pannus with dynamic MR imaging en- hanced with Gd-DTPA. Radiology 1990;176:473-477 15.,,,,,.. 2000;42:825-831 16.,,,,,. : 1999;41:1007-1013 17. Hong SH, Kim SM, Ahn JM, Chung HW, Shin MJ, Kang HS. Tuberculous versus pyogenic arthritis: MR imaging evaluation. Radiology 2001;218:848-853 18. Lee SK, Suh KJ, Kim YW, Ryeom HK, Kim YS, Lee JM, et al. Septic arthritis versus transient synovitis at MR imaging: preliminary assessment with signal intensity alterations in bone marrow. Radiology 1999; 211:459-465 1. Ruiz ME, Erickson SJ, Carrera GF, Hanel DP, Smith MD. Monoarticular gout following trauma: MR appearance. J Comput Assist Tomogr 1993;17:151-153 2. Archibeck MJ, Rosenberg AG, Sheinkop MB, Berger RA, Jacobs JJ. Gout-induced arthropathy after total knee arthroplasty: a report of two cases. Clin Orthop Relat Res 2001;392:377-382 3. Rogachefsky RA, Carneiro R, Altman RD, Burkhalter WE. Gout presenting as infectious arthritis: two case reports. J Bone Joint Surg Am 1994;76:269-273 4. Yu JS, Chung C, Recht M, Dailiana T, Jurdi R. MR imaging of tophaceous gout. AJR Am J Roentgenol 1997;168:523-527 5. Hsu CY, Shih TT, Huang KM, Chen PQ, Sheu JJ, Li YW. Tophaceous gout of the spine: MR imaging features. Clin Radiol 2002;57:919-925 19.,,,,,. : 2002;47:657-664 20. Yu KH, Luo SF, Liou LB, Wu YJ, Tsai WP, Chen JY, et al. Concomitant septic and gouty arthritis--an analysis of 30 cases. Rheumatology 2003; 42:1062-1066 170
MR Imaging Findings of Acute Gouty Arthritis 1 Gyung Kyu Lee, M.D. 1, 4, Jee Young Lee, M.D. 2, Jin-Suck Suh, M.D. 3, Jae-Boem Na, M.D. 4, Ik Yang, M.D., Ik Won Kang, M.D., Eil Seong Lee, M.D., Dae Hyun Hwang, M.D. Seong Whi Cho, M.D., Seon Jung Min, M.D., Eun-Sook Ko, M.D. 4, Kyung Jin Suh, M.D. 2 1 Department of Radiology, Hallym University College of Medicine 2 Department of Radiology, Dankook University College of Medicine 3 Department of Radiology, Yonsei University College of Medicine 4 Department of Radiology, Gyeongsang National University College of Medicine Purpose: The purpose of this study was to describe the clinical and MR imaging features of acute gouty arthritis and to define the characteristic findings that would be helpful for differentiating acute gouty arthritis from septic arthritis. Materials and Methods: The authors retrospectively studied seven patients who suffered from acute gouty arthritis. The MR imaging findings were analyzed by two musculoskeletal radiologists who focused on joint effusion, subchondral bone erosion, bone marrow edema, synovial thickening (regular and even, or irregular and nodular), and the soft tissue changes (edema or abscess). The clinical records of the patients were reviewed with regard to age and gender, the clinical presentation and the laboratory findings (serum uric acid, WBC, erythrocyte sedimentation rate, C-reactive protein and synovial fluid culture). Results: The patients consisted of six men and one woman whose mean age was 41 years (age range: 2465 years). The joints involved were the knee (n=6), and ankle (n=1). Two patients had medical histories of gouty attacks that involved the first metatarsophalangeal joint. In six cases, the serum uric acid level during acute attacks was elevated. In all the patients, the affected joint became swollen, hot, erythematous and extremely tender, and this was accompanied by a high ESR and a high C-reactive protein level at the time of presentation. The results of Gram stain and culture of the synovial fluid were negative. In all patients, the MR images showed large amounts of joint effusion, thick irregular and nodular synovial thickening and soft tissue edema without subchondral bone erosions and soft tissue abscess. In one case, subchondral bone marrow edema of the medial femoral condyle was present. In five cases, there were multiple low signal foci in the joint on the spin-echo T2-weighted MR image. Conclusion: Even though the MR imaging findings of acute gouty arthritis are nonspecific, it should be considered as a possible diagnosis when a large amount of joint effusion, irregular and nodular synovial thickening and soft tissue edema without subchondral bone erosion, bone marrow edema or soft tissue abscess are seen in the knee or ankle joint, and especially if this is accompanied by the clinical and laboratory features of infection Index words : Gout Joints, MR Arthritis Ankle Address reprint requests to : Kyung Jin Suh, M.D., Department of Radiology, Dankook University College of Medicine 16-5 Anseo-dong, Cheonan, Chungnam 330-715, Korea. Tel. 82-41-550-3955 Fax. 82-41-552-9674 E-mail: rad@chol.com 171