Consideration of non-tuberculous mycobacteria in the differential diagnosis in cases of localised tenosynovitis is paramount for diagnosis. Treatment based on graduated diagnostic steps, surgery and drugs (empirical followed by directed drugs) can achieve favourable clinical outcomes.
Background
Seronegative Oligo/Polyarthritis combines a set of diseases including gout as a possible differential diagnosis.
The identification of monosodium urate crystals is the gold standard for the proof of gout. However, the puncture of small finger and toe joints maybe a challenge and is therefore often not applicable.
Methods
A retrospective analysis of 49 patients was used to investigate the value of Dual-Energy CT for differential diagnosis in patients with seronegative arthropathies.
Puncture and analysis of the joint fluid was possible in 15 patients, whereas Dual-Energy CT without puncture could be performed in the remaining 34 patients.
Results
In the first group of patients (n=15), where a crystal analysis was available, urate crystals could be indentified in 14 and Dual-Energy CT investigation confirmed monosodium urate depositions in 11 of these patients.In 3 cases with positive urate crystal detection in joint fluid gout-CT was negative.In one case pyrophosphate crystals were identified and no urate depositions in gout-CT could be detected.
In the second group (n=34) joint puncture could not be performed as the affected joints were small finger and toe joints.21 of these patients revealed urate depositions in Dual-Energy CT. In these cases the diagnosis of gout was confirmed and appropriate therapy could be started. 17 out of these 21 patients had elevated uric acid levels.
Conclusions
Dual-Energy CT can be applied as a tool for diagnosing gout in patients with seronegative inflammatory arthropathy especially in the case of polyarticular joint involvement and no possibility of joint puncture.
References
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W Zhang, M Doherty, T Bardin et al. Eular evidence based recommendations for gout. Part II: Management.Report of a task force of the standing committee for international clinical studies including therapeutics/ESCISIT). Ann Rheum Dis 2006;65:1312-1324
N Dalbeth, B Clark, K Gregory et al. Mechanisms of bone erosion in gout: a quantitative analysis using plain radiography and computed tomography. Ann Rheum Dis 2009; 68:1290-1295
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S Nicolaou, CJ Yong-Hing, S Galea-Soler. Dual Energy CT as a Potential New Diagnostic Tool in the Management of Gout in the Acute Setting. AJR 2010;194:1072-1078
G.Strau, M. Mustak, M Kasper. Dual-Energy-Computertomografie (article in German). Jatros Orthopädie & Rheumatologie 5/2011
Disclosure of Interest
None Declared
With this treatment regimen the patient has showed complete remission of AIP and arthritis for 36 months. MTX may be successful as an initial basic treatment to reach better control of autoimmune-related extrapancreatic manifestations.
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