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7.1 Rheumatoid Arthritis 253
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syndrome is characteristically associated with high
serum CRP and ESR levels, with sero-negative RF
and ANA levels. Characteristically, the serum level of
vascular endothelial growth factor (VGEF) is higher
than any other rheumatic disorder, and it helps to
establish the diagnosis with the radiological fi ndings.
The condition responds well to steroid therapy.
Jaccoud’s arthropathy is a nonerosive, chronic, progres-
sive, almost painless arthropathy characterized by severe
deformities and joint sublaxations of the hands and feet
with well-preserved functions. In the hands, Jaccoud’s
arthropathy presents classically with painless ulnar
deviation, swan-neck, and boutonnière deformities of
the fi ngers and thumb, making the disease easily mistaken for RA. Jaccoud’s arthropathy is classically seen
in cases of long-standing rheumatic fever, SLE, scleroderma, sarcoidosis, dermatomy ositis, and rarely psoriasis. However, the disease can present in the absence of
other diseases (idiopathic Jaccoud’s arthropathy).
Signs on Plain Radiographs
Osteoporosis that can be generalized or focal (juxta-articular),
due to hyperemia and disuse (Figs. 7.1.3 and 7.1.4 ).
Joint space narrowing due to destruction of the articular
surface (Figs. 7.1.3 and 7.1.4 ). Typically, the distal interpha-
langeal joint (DIP) is spared in RA.
Marginal erosions and subchondral cysts formation (geodes)
(Fig. 7.1.3 ). Up to 47% of patients develop erosions within
1 year after onset of RA.
Boutonnière deformity : fl exion at the proximal interphalangeal
joint (PIP) and hyperextension at the DIP (Figs. 7.1.1 and 7.1.5 ).
Swan-neck deformity : hyperextension at the PIP and fl exion at
the DIP (Fig. 7.1.1 ) .
: rare fi nding that is characterized by laxity at the
Mallet fi nger
insertion of the extensor tendon on the distal phalanx, thus
causing the distal phalanx to drop.
Hitchhiker thumb deformity : fl exion at the proximal
metacarpophalangeal joint of the thumb and hyperextension
at the DIP joint (Figs. 7.1.1 and 7.1.6 ).
Mutlans deformity ( Opera-glass hand ): a severe hand deformity
seen in rapidly progressing RA characterized by severe osteoporosis and phalangeal resorption that causes shortening of the
fi ngers. The carpal and metacarpal bones are commonly resorbed
and crumbled due to intercarpal/metacarpal ligaments disruption
(Figs. 7.1.1 and 7.1.7 ). Grossly, the fi ngers are shor tened and the
skin is wrinkled, giving the impression that the phalanges were
retraced one into another like opera glass (Fig. 7.1.1 ).
Hammer toe deformity : the toe is bent at the middle joint, so
that it resembles a hammer (Fig. 7.1.1 ). It is commonly seen
aff ecting the second, third, or fourth toes.
Due to muscular atrophy, shifting deformities can arise in
hands (ulnar deviation), or feet (fi bular deviation) (Fig. 7.1.1 ).
In the humerus, RA can cause “ high-riding shoulder ” due to
rotator cuff tear.
In the hip joint, RA causes migration of the femoral head in an
axial fashion in the hip joint. In contrast, osteoarthritis causes
migration of the femoral head in a superior fashion.
Involvement of the foot may occur in up to 90% of cases. The
fi rst and the fi fth metatarsophalangeal joints are aff ected in
up to 50% of cases (Fig. 7.1.4 ).
Atlantoaxial sublaxation is present when the distance
between the posterior aspect of the anterior arch of the atlas
and the odontoid process is >3 mm in adults or >5 mm in
children on fl exion radiographs. Atlantoaxial sublaxation
arises in RA with an incidence of 16–36% of cases, presumably secondary to synovitis causing laxity or tearing of the
transverse atlantoaxial ligament (Fig. 7.1.8 ). The atlantoaxial
sublaxation can progress into atlantoaxial dissociation.
Atlantoaxial impaction : occurs when both the facets of the atlas and
axis collapse due to erosions. The atlas will articulate with the body
of the axis instead of the odontoid process. On lateral radiographs,
the odontoid process will be seen inside the foramen magnum.
In juvenile rheumatoid arthritis , there is fusion between the
carpometacarpal joint of the index and middle fi ngers, and
enlargement of the epiphysis and the metaphysis end of long bones.
In Still’s disease , radiographic features in the hands are a mix
between RA and psoriasis arthropathy with aff ection of the
DIP joints in a similar fashion to psoriasis arthropathy erosions.
Lung fi brosis can be seen in long-standing RA (Fig. 7.1.9 ).
In PPsRD , patients are classically young presenting with widening
of the metaphyses of long bones involving the proximal femur
and the distal knee, epimetaphyseal enlargement of the
metacarpal heads and the phalanges, mega os trigonum, and
fl attened vertebrae (platyspondyly) with narrowed disc spaces
and irregular endplates mimicking Scheuermann’s disease. The
fl attened vertebrae and irregular endplates are seen mainly in
the thoracic region in Scheuermann’s disease, whereas in PPsRD,
the fl attened vertebrae with irregular endplates involve the
whole spine almost equally (key diagnostic feature).
In RS 3 PE syndrome , in contrast to RA, plain radiographs show
absent joint erosions.
Jaccoud’s arthropathy, in contrast to RA, plain radiographs of
AQ1
the hands typically show joint deformities in the absence of
bone erosions or cartilage destruction.
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7.1
Fig. 7.1.5. Lateral plain radiograph of the fi ngers of a patient
with RA shows Boutonnière deformity ( arrowhead )
Fig. 7.1.3. Plain radiograph of the hand of a patient with RA
shows diffuse osteoporosis and reduced space narrowing
between the carpal bones, and between the carpal bones and the
distal radioulnar joint with formation of geodes ( arrowhead )
Fig. 7.1.6. Plain radiograph of the thumb shows fl exion at the
proximal metacarpophalangeal joint of the thumb and hyperextension at the DIP joint ( arrowheads ). (Hitchhiker thumb deformity)
Fig. 7.1.4. A plain radiograph of a patient foot with RA shows marginal erosions of the metatarsals ( solid arrowheads ), joint space nar-
rowing of the metatarsophalangeal and interphalangeal joints ( hollow
arrowheads ), and patchy osteoporosis ( arrows ) There is old mid-dia-
physeal fracture with callus formation of the 2nd metatarsal bone
7.1 Rheumatoid Arthritis 255
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Fig. 7.1.9. Posteroanterior chest radiograph of a patient with RA
shows diffuse reticulonodular interstitial pattern refl ecting lung
fi brosis
Fig. 7.1.7. Plain radiograph of the hand of a patient with RA
shows crumbling of the carpal bones with severe deformity of
the hand plus osteoporosis (Mutlans deformity)
Fig. 7.1.8. Lateral plain
radiograph of the atlantoaxial
joint of a patient with
atlantoaxial sublaxation due
to RA shows a signifi cant gap
between the anterior arch of
the atlas and the odontoid
process ( arrowhead ) on
extension radiograph
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Signs on MRI
Diff erent manifestations of infl ammation can be seen involving
high signal intensity on T2W images of the muscles, bone
7.1
marrow, tendons, and the articular surface due to eff usion.
After contrast injection, enhancement of the thickened
synovium (pannus) can be seen, and it is a typical sign of RA.
Extensor carpi ulnaris tendenitis is a typical fi nding in early
RA. On T2W images, fl uid signal is observed around the
tendon sheath with change in the tendon signal intensity.
Popliteal ( Baker ) cyst is a synovial juxta-articular cyst fi lled
with fl uid collection that is lined by synovial cells that may, or
may not, communicate with the joint. Baker’s cyst is a synovial
cyst that is located in the posteromedial aspect of the knee,
and represents a fl uid extension through a slit-like communication between knee joint and the gastrocnemius-semimembranosus bursa. The cyst is typically seen as a fl uid collection
that passes between the gastrocnemius tendon and the
semimembranosus tendon (
rim enhancement after contrast injection that mimics
neoplasm. Rupture of the cyst may present with severe
sudden pain that mimics thrombophlebitis or deep venous
thrombosis. If the cyst is large enough to compress the
popliteal artery, calf claudication arises rarely.
Rice bodies are small, rice-like hypointense bodies seen inside
large joints like knee and hip joints due to cartilage
destruction or synovial proliferation (Fig. 7.1.11 ). Rice bodies
are an uncommon feature, and very characteristic of RA.
Cerebral rheumatic nodules are seen as focal parenchymal
lesions with high signal intensities on T2W and FLAIR images,
associated with adjacent leptomeningeal enhancement
(Fig. 7.1.12 ). Rheumatoid pachymeningitis may occur rarely.
In PPsRD , the whole vertebral column shows fl attened
vertebrae with irregular endplates and multiple intervertebral
disc herniations along almost the whole spine. Remember
that the MRI picture is seen in a child or a young man, not in a
geriatric person with diff use degenerative changes.
In RS 3 PE syndrome , MRI typically shows signs of tenosynovitis
with synovium thickening and enhancement postcontrast
injection.
Fig. 7.1.10 ). The cyst may show
Fig. 7.1.10. Axial PD knee MRI shows popliteal (Baker) cyst
seen as a fl uid collection that passes between the gastrocnemius
tendon and the semimembranosus tendon ( arrowhead )
Fig. 7.1.11. Coronal STIR shoulder MRI shows right shoulder
joint effusion with multiple intra-articular hypointense lesions
(rice bodies). Differential diagnosis of such sign is synovial
chondromatosis, which classically shows intra-articular calcifi cation best demonstrated on plain shoulder radiograph
7.1 Rheumatoid Arthritis 257
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Fig. 7.1.12. Axial brain
FLAIR ( a ) and T1W
postcontrast ( b )
MR-illustrations demonstrate
the classical fi ndings of
cerebral rheumatoid nodule.
There is T2 hyperintense
lesion on ( a ) associated with
leptomeningeal enhancement
of the adjacent meningies ( b )
For Further Reading
1 . Rosenstein ED et al Felty’s and pseudo-Felty’s syndromes.
Semin Arthritis Rheum. 1991;21:129–42
2 . Hurd ER. Extraarticular manifestations of rheumatoid
arthritis. Semin Arthritis Rheum. 1979;8, 151–176
3 . Tehranzadeh J et al Advanced imaging of early rheumatoid
arthritis. Radiol Clin North Am. 2004;42:89–107
4 . Sommer OJ et al Rheumatoid arthritis: a practical guide to
the state-of-the-art imaging, image interpretation, and
clinical implications. RadioGraphics. 2005; 25:381–98
5 . Bancroft LW et al Cysts, geodes, and erosions. Radiol Clin
North Am. 2004;42:73–87
6 . Calatayud J et al Nodular pulmonary amyloidosis in a
patient with rheumatoid arthritis. Clin Rheumatol. 2007;26:
1797–98
7 . B e d n a řik J et al Median nerve mononeuropathy in spondy-
lotic cervical myelopathy: double crush syndrome? J
Neurol. 1999;246:544–51
8 . Beaman FD et al MR imaging of cysts, ganglia, and bursae
about the knee. Radiol Clin North Am. 2007;45:969–82
9 . Ragan C et al Rheumatoid arthritis. Dis Mon. 1955;1:2–51
10 . Zolcinski M et al Central nervous system involvement as a
major manifestation of rheumatoid arthritis. Rheumatol
Int. 2008;28:281–83
1 1 . G o ńi MA et al Rheumatoid nodulosis: a puzzling variant of
rheumatoid arthritis. Clin Rheumatol. 1992;11:396–401
12 . Bordel Gómez MT et al Rheumatoid nodulosis: report of
two cases. JEADV 2003;17:695–8
13 . Paci R et al Neuroradiological picture of cerebral vasculitis
in rheumatoid arthritis. Neuroradiology. 1983;25:343–5
14 . Cellerini M et al MRI of cerebral rheumatoid pachymenin-
gitis: report of two cases with follow-up. Neuroradiology.
2001;43:147–50
15 . Solomon WM et al Chronic absorptive arthritis or opera-glass
hand: report of eight cases. Ann Rheum Dis. 1950;9: 209–20
16 . Marik I et al Dominantly inherited progressive pseudor-
heumatoid dysplasia with hypoplastic toes. Skeletal Radiol.
2004;33:157–64
17 . Ehl S et al Clinical, radiographic, and genetic diagnosis of
progressive pseudorheumatoid dysplasia in a patient with
sever polyarthropathy. Rheumatol Int. 2004;24:53–6
18 . Kaya A et al Clinical and radiological diagnosis of progres-
sive pseudorheumatoid dysplasia in two sisters with sever
polyarthropathy. Clin Rheumatol. 2005;24:560–64
19 . Mampaey S et al Progressive pseudorheumatoid dysplasia.
Eur Radiol. 2000;10:1832–5
20 . Weissman BNW et al Prognostic features of atlantoaxial
sublaxation in rheumatoid arthritis patients. Radiology.
1982;144:745–51
21 . Tada Y et al Flexor tenosynovitis of the ahnd as an initial
manifestation of systemic lupus erythematosus. Mod
Rheumatol. 2000;10:173–5
22 . Sivas F et al Idiopathic Jaccoud’s arthropathy. APLAR J
Rheumatol. 2005;8:60–2
23 . Wu Y et al Jaccoud’s arthropathy and psoriatic arthritis, a
rare association. Rheumatol Int. doi: 10.1007/s00296-0091017-1
2 4 . G a l v ăo V et al Profi le of autoantibodies in Jaccoud’s
arthropathy. Joint Bone Spine. 2009;76:356–60
25 . Sugisaki K et al Remitting seronegative symmetrical syno-
vitis with pitting edema (RS3PE) syndrome following
spontaneous rupture of a gouty tophus. Mod Rheumatol.
2008;18:630–3
26 . Manganelli P et al Remitting seronegative symmetrical
synovitis with pitting edema in a patient with myelodysplastic syndrome and relapsing polychondritis. Clin
Rheumatol. 2001;20:132–5
27 . Unlu Z et al Magnetic resonance imaging fi ndings in a case
of remitting seronegative symmetrical synovitis with pitting edema. Clin Rheumatol. 2005;24: 648–51
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7.2
7.2
Ankylosing Spondylitis
(Marie–Strümpell Disease)
Ankylosing spondylitis (AS) is a chronic, progressive
infl ammatory disease of unknown origin that affects the
axial skeleton (vertebral column plus the pelvis), and is
characterized by bilateral sacroiliitis, stiffness of the axial
joints (ankylosis), and syndesmophytes formation.
AS is a rheumatoid factor sero-negative arthritis
that is positively associated with HLA-B27. HLA
stands for human leucocyte antigen (HLA) system. In
the body, there are two classes of HLA antigens. Class
I HLA is expressed by the human cells for histocompatibility, so the body knows that these cells are its
own cells. Class I HLA antigens have an important
role in transplant rejection. Class II HLA antigens are
expressed by the immunocompetent cells including
macrophages, Langerhanse cells, B cells, and some T
cells. HLA-B27 antigen is associated with AS in 90%
of cases. However, only 5% of patients with positive
HLA-B27 develop AS.
Patients with AS often present with back stiffness,
low back ache, and discomfort in thighs and buttocks.
Extra-skeletal manifestations include anterior uveitis,
ascending aortitis and bronchiolitis obliterans with organizing pneumonia (cryptogenic organizing pneumonia).
Cauda equina syndrome is an uncommon complica-
tion of AS. Patients classically present with symptoms
related to compression of the cauda equine such as low
back and lower extremities pain, impotence, overfl ow
incontinence, cutaneous sensory defects (paresthesia),
and motor dysfunction. Up to 30% of patients describe
severe burning or shooting pain in the lower limbs.
iliac side of the joint. In advanced stage of the disease, the
erosions increase in size and widen the sacroiliac joint. Later,
sclerosis of the sacroiliac joint occurs (Fig. 7.2.1 ).
Vertebral bodies squaring
is an early manifestation of AS that
arises due to infl ammation of the peripheral fi bers of the
annulus fi brosis at their attachment to the upper and lower
corners of the vertebral bodies (enthesitis). Enthesitis means
infl ammation of the entheses, the location where a tendon or
a ligament is inserted into a bone. Erosions of the vertebral
body at these areas make the vertebral body look square in
shape (Fig. 7.2.2 ).
Syndesmophytes are para-vertebral ossifi cations that resemble
osteophytes, except that they arise vertically from one
vertebra to the other (Fig. 7.2.3 ), while osteophytes run in a
horizontal fashion along the vertebral bodies. When the
syndesmophytes are diff usely aff ecting the vertebral column,
the vertebral column is said to have a “bamboo spines
appearance” (Fig. 7.2.4 ). Syndesmophytes are ossifi cations of
the annulus fi brosus–longitudinal ligament complex as a
healing process after enthesitis.
is longitudinal radiopaque line seen along the
Dagger sign
vertebral column representing calcifi cation of the supraspinous ligament (Fig. 7.2.5 ).
Trolley track sign : Three dense radiopaque lines are seen along
the vertebral column representing calcifi cation of the
supraspinous and ankylosis of the facets joints.
Signs on Radiograph
Sacroiliitis involvement is almost always in a bilateral and
symmetrical fashion in AS (90% of cases). However, unilateral
involvement may occur in 10% of cases. Radiological fi ndings
include multiple small erosions (rat bite erosions) along the
Fig. 7.2.1. Anteroposterior plain radiograph of the hip of a
patient with advanced ankylosing spondylitis (AS) shows complete sclerosis of the sacroiliac joints bilaterally ( arrowheads )
7.2 Ankylosing Spondylitis (Marie–Strümpell Disease) 259
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Fig. 7.2.2. Lateral plain radiograph of the thoracic vertebrae in
advanced stage of AS shows squaring of the vertebrae
Fig. 7.2.3. Anteroposterior plain radiograph of the thoracic vertebrae shows syndesmophytes ( arrowheads )
Fig. 7.2.4. Anteroposterior plain radiograph of the thoracic vertebrae shows the classic appearance of bamboo spines
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7.2
Signs on MRI
Cauda equina syndrome typically presents as enlargement of
the thecal sac, multiple dorsal diverticula, with asymmetric
scalloped erosions of the bony canal.
is enthesitis at the insertion of the annulus
Romanus lesion
fi brosus–longitudinal ligament complex. There is low T1
signal intensity, high T2 signal intensity, and marked contrast
enhancement within the annulus fi brosus at the discovertebral junction, indicating active enthesitis (Fig. 7.2.6 ). When
the active enthesitis starts to heal, it forms sendesmophytes.
Anderson lesion is a focal erosive change in the vertebral
endplate that resembles bacterial discitis (Fig. 7.2.7 ). Typical
features of Anderson lesion include disc space narrowing,
focal bone destruction at the vertebral endplate adjacent to
the disc, surrounding sclerosis, and local kyphosis.
Diff erentiation between bacterial discitis and Anderson
disease can be diffi cult in patients with AS. However, the
vertebral disc is typically involved in bacterial discitis, while in
Anderson lesion the disc signal is generally preserved or
shows degeneration. Moreover, perivertebral eff usion and
intradiscal eff usion are commonly found with bacterial
discitis, whereas they are rare with Anderson lesion. After
contrast injection, both Anderson lesion and bacterial discitis
show contrast enhancement. Bacterial discitis high T2 signal
intensity is due to hyperemia and edema, while enhancement
in Anderson lesion is due to granulation tissue formation.
Fig. 7.2.5. Anteroposterior plain radiograph of the thoracic vertebrae shows the dagger sign
Fig. 7.2.6. Sagittal thoracic
T1W ( a ) and STIR ( b ) MRI
show enthesitis at the anterior
superior and anterior inferior
vertebral endplates of two
adjacent vertebrae (Romanus
lesion) ( arrowheads )
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Fig. 7.2.7. Sagittal lumbar T1W MR illustration demonstrates
Anderson’s lesions ( arrowheads )
D i ff erential Diagnoses and Related Diseases
SAPHO syndrome is a rare musculoskeletal disease
of unknown origin characterized by S ynovitis, A cne,
P ustulosis of the palmar and plantrar skin surfaces,
H yperostosis of the bones, and O steitis. Patients
with the adult form of SAPHO syndrome usually
present with unilateral Sacroiliitis and syndesmophytosis that may mimic the radiographic picture of
AS.
Diffuse idiopathic skeletal hyperostosis ( DISH ) is a
disease characterized by multisegmental vertebral
fusion due to ligamentous calcifi cation and ossifi cation. The disease is commonly seen in the cervical
and the thoracic vertebrae. Patients are usually above
70 years of age presenting with neck pain and stiffness. DISH can be mistaken with AS. Characteristic
radiological signs of DISH include fl owing vertebral
ossifi cation of at least four contiguous vertebral bodies, broad band of ossifi cation along the anterolateral
aspect of each vertebra (Fig. 7.2.8 ), absence of dege-
nerative disc disease, and absence of sacroiliac joints
disease.
Fig. 7.2.8. Lateral plain radiograph of the cervical vertebrae shows
multisegmental vertebral fusion due to ligamentous calcifi cation
and ossifi cation due to diffuse idiopathic skeletal hyperostosis
(DISH) ( arrowheads )
For Further Reading
1 . Uppal SS et al Ankylosing spondylitis and undifferentiated
spondyloarthropathies in Kuwait: a comparison between
Arabs and South Asians. Clin Rheumatol. 2006;25:219–24
2 . Pham T. Pathophysiology of ankylosing spondylitis: what’s
new ? Joint Bone Spine. 2008;75:656–60
3 . Sant SM et al Cauda equina syndrome in ankylosing spon-
dylitis: a case report and review of the literature. Clinical
rheumatol. 1995;14:224–6
4 . Soeur M et al Cauda equina syndrome in ankylosing spon-
dylitis. Anatomical, diagnostic, and therapeutic considerations. Acta Neurochirurgica. 1981;55:303–15
5 . Lee Bennett D et al Spondyloarthropathies: ankylosing
spondulitis and psoriatic arthritis. Radiol Clin North Am.
2004;42:121–34
6 . Quagliano PV et al Vertebral pseudoarthrosis with diffuse
idiopathic skeletal hyperostosis. Skeletal Radiol. 1994;23:353–5
7 . Jordana X et al The coexistence of ankylosing spondylitis
and diffuse idiopathic skeletal hyperostosis-a postmortem
diagnosis. Clin Rheumatol. 2009;28:353–6
8 . Jevtic V et al Marginal erosive discovertebral “Romanus”
lesions in ankylosing spondylitis demonstrated by contrast
enhanced Gd-DTPA magnetic resonance imaging. Skeletal
Radiol. 2000;29:27–33
9 . Tsuchiya K et al Discovertebral lesion in ankylosing spon-
dylitis: differential diagnosis with discitis by magnetic resonance imaging. Mod Rheumatol. 2002;12:113–7
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7.3
7.3
Gout Arthritis
Gout is a clinical condition characterized by increased
serum uric acid levels (hyperuricemia) with deposition
of uric acid monocrystals in the synovial fl uid, initiating acute infl ammatory reaction that leads to arthritis.
Gout is the most common cause of infl ammatory
arthritis in men >40 years of age.
Hyperuricemia is defi ned as urate levels >7 mg/dL in
men and menopausal women, or urate levels >6 mg/dL
in premenopausal women. Plasma urate level >7 mg/dL
exceeds the saturation for urate solubility at normal
body temperature and blood PH.
Not every patient with hyperuricemia develops
symptoms of gout. Gout can result from impaired uric
acid clearance by the kidney (primary gout), or due to
increased production of uric acid for a variety of
causes, increased turnover of nucleic acids, or from
decreased clearance of uric acid (secondary gout). Up
to 80% of cardiac transplant patients develop hyperuricemia, and 10% develop gout after a mean of 1.5 years
posttransplantation.
Uric acid monocrystals are needle-shaped negatively birefringent crystals, and they are the main product of purine catabolism. They deposit within the
synovium or the renal parenchyma forming chalkywhite deposits that initiate painful arthritis and renal
disease. High uric acid precipitation within the renal
tubules can result in uric acid renal stones formation.
In gout arthritis (GA), deposition of the urate crystals (tophi) within the synovial fl uid and the synovial
membrane causes infl ammation. With time, a soft tissue pannus forms within the joint which will start to
erode the intra-articular cartilage and the subchondral
bone. The monosodium urate crystals may also deposit
in the tendon, ligaments, bursae, and other organs like
the ear, nose, and skin.
Rarely, gout can involve the spines resulting in sclerotic bony lesions, cervical pain, or paraplegia if the
spinal cord is affected.
It takes 4–6 years for gout to cause detectable radiographic signs, and the patients are usually treated
before the radiological signs start to appear. Because
of this, GA radiographic features are not commonly
seen, although they have characteristic patterns.
Signs on Plain Radiographs and MRI
There are typically cortical bony erosions with well-defi ned
sclerotic margin in the absence of steoporosis (Figs. 7.3.1 and
7.3.2 ). Disuse osteopenia may occur in late stages of the disease.
Podagra is a term used to describe gout tophi aff ecting the
metatarsophalangeal joint of the great toe; it is seen as
erosion of the fi rst metatarsal bone often associated with
para-articular soft tissue swelling (Fig. 7.3.3 ). Podagra shows
signs of infl ammation when the process of tophus formation
is active (Fig. 7.3.4 ).
Cartilage calcifi cation (chondrocalcinosis) can be seen in up to
40% of patients.
Vertebral gout may present as an osteolytic vertebral lesion
with sclerotic margin.
Fig. 7.3.1. Plain radiograph of the metacarpal heads shows bony
erosion with sclerotic margin in the absence of osteoporosis
( arrowhead ), a typical fi nding of gout arthritis (GA)
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