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OH, THE PLACES URATE WILL GO!

A Vodcast Series on Systemic Urate Deposition (SUD) with Dr. Ada Kumar, Radiologist

Dr. Kumar brings her 15 years of expertise in radiology to bear to investigate how imaging is yielding insights into our understanding of gout, systemic deposition of urate, and its potential implications on the body.

Dr. Ada Kumar is the former chief resident at Brigham and Women’s Hospital, Harvard Medical School, and has completed a fellowship in musculoskeletal imaging at the University of Chicago.

Dr. Ada Kumar
Dr. Ada Kumar

Radiologist

The not-so-great places urate can deposit

Once thought to be limited mainly to bones and joints, it has become clear that uric acid crystals deposit in numerous body systems and vital organs.1

Hosted by Dr. Ada Kumar, this video podcast (vodcast) series examines the surprising and concerning places where urate deposition has been found in the body, and what these findings mean for patients with systemic urate deposition.

EPISODE 1:

A HEART-TO-HEART ABOUT GOUT

PART 1

Dr. Kumar takes a look at the potential dangers of urate deposition in the heart with a focus on arterial deposition.

EPISODE 1:

A HEART-TO-HEART ABOUT GOUT

PART 2

In part 2 of her investigation of urate deposition in the heart, Dr. Kumar examines deposits in the cardiac valves and myocardium.

EPISODE 2:

URATE IN THE KIDNEYS? NO KIDDING!

Dr. Kumar looks at the connection between urate deposition in the kidney and decreased renal function.

EPISODE 3:

SPINE-TINGLING IMAGES— URATE DEPOSITION IN THE BACK

Dr. Kumar explores evidence of gout and urate deposition along the spine.

EPISODE 4:

OPEN YOUR EYES! LOOKING AT URATE DEPOSITION

Dr. Kumar analyzes medical images of urate deposition in the eyes and its effect on ocular function.

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Damage coming into focus: Inside SUD

The extent of urate crystal deposition can be difficult to detect through physical examination alone2; thus, various imaging techniques can be employed to uncover systemic urate crystal deposition and its resulting damage.1,3

See systemic deposition now

MRI of spine and acute kidney injury

(43-year-old male) Axial T2-weighted MRI of spine revealing bilateral, mixed-intensity, abnormal soft tissue, involving the right and predominantly the left T11 pedicle (white arrows)

Reproduced from Spinal tophaceous gout encasing the thoracic spinal cord, Subrati N, et al, 1-3, © 2016 with permission from BMJ Publishing Group Ltd.

REFERENCE

Subrati N, et al. BMJ Case Rep. 2016:brc2016214869.

DECT imaging of heart

DECT (Dual-Energy Computed Tomography) imaging revealing approximately 20 mm2 of uric acid deposition in a patient’s aortic arch (green areas)

Image used with permission from S. Barazani.

REFERENCE

Barazani S, et al. https://acrabstracts.org/abstract/detection-of-uric-acid-crystals-in-the-vasculature-of-patients-with-gout-using-dual-energy-computed-tomography/. Accessed September 2, 2020.

Eye image 1 - exterior

Bulbar conjunctiva in patient with tophaceous gout showing many distinct granular deposits of chalky white material (white arrow points to area)

Image used with permissions from Lo WR, et al. Am J Ophthalmol. 2005;140(6):1152-1154.

REFERENCE

Lo WR, et al. Am J Ophthalmol. 2005;140:1152-1154.

Eye image 2 - interior

Light micrograph of bulbar conjunctiva showing multiple tophi composed of eosinophilic material surrounded by histiocytes and foreign body giant cells

Image used with permissions from Lo WR, et al. Am J Ophthalmol. 2005;140(6):1152-1154.

REFERENCE

Lo WR, et al. Am J Ophthalmol. 2005;140:1152-1154.

DECT imaging of body joints

(53-year-old male) DECT imaging revealing large urate crystal deposits along bilateral feet and ankles, the right Achilles tendon, hand, wrist, and proximal elbow (green areas)

Photo courtesy of S. Nicolaou.

REFERENCE

Nicolaou S, et al. AJR Am J Roentgenol. 2012;199(suppl 5):S78-S86.

DECT imaging of knee joints

(48-year-old male) DECT imaging showing gout through the bilateral presence of urate crystal deposits in knee joints (green areas)

Photo courtesy of S. Nicolaou.

REFERENCE

Nicolaou S, et al. Am J Roentgenol. 2012;199(suppl 5):S78-S86.

DECT scan of hip joint

(63-year-old-female) DECT scan revealing deposition of urate crystals in the right temporomandibular joint (green areas)

Image used with permission, from RadioGraphics 2011;31:1365-1375. © RSNA

REFERENCE

Desai MA, et al. RadioGraphics. 2011;31:1365-1375.

DECT imaging of foot

DECT imaging revealing urate crystal deposits along the Achilles tendon, as well as the metatarsophalangeal joints, midfoot, and ankle joint (green areas)

Image used with permission from M. Biermann.

REFERENCE

Biermann M, et al. Gout and Hyperuricemia. 2014;1:122-126.

MRI of liver

(53-year-old male) MRI of liver displaying alcoholic cirrhosis and an atypical nodule. Nodule was later confirmed to be a gouty tophus (white arrow)

Image used with permission of Elsevier.

REFERENCE

Varinot J, et al. Clin Res Hepatol Gastroenterol. 2011;35:855-856.

CT of chest wall

(73-year-old male) Chest CT scan revealing a cystic mass immediately anterior to the mid sternum. Needle aspiration and microscopy revealed large quantities of monosodium urate crystals (white arrow)

Reproduced from BMJ Case Rep, Wolfenden TPJ, et al, © 2014 with permission from BMJ Publishing Group Ltd.

REFERENCE

Wolfenden TPJ, et al. BMJ Case Rep. 2014;2014:bcr2013203294.

Radiograph of lower back -1

(69-year-old female) Radiographs of pelvis revealing intra-articular and para-articular bone erosions. Based on laboratory and radiographic findings, a diagnosis of uncommon axial gouty arthropathy was made (white arrows)

Reproduced with permission of The Foundation Acta Radiologica, from Spinal and sacroiliac gouty arthritis: report of a case and review of the literature, Cardoso FN, et al, 3, 8, © 2014; permission conveyed through Copyright Clearance Center, Inc.

REFERENCE

Cardoso FN, et al. Acta Radiol Short Rep. 2014;3:1-5.

Systemic deposition

Negatively birefringent crystal image (purple) used with permission from Park JJ, et al. BMJ Open. 2014;4(7):e005308.

Myocyte inclusions in the myocardium image used with permission from Frustaci A, et al. Ann Intern Med. 2020;172(5):363-365.

Kidney autopsy image used with permission from Nickeleit V, Mihatsh MJ. Nephrol Dial Transplant. 1997;12(9):1832-1838.

Spinal DECT scan used with permission from Wang JX, et al. BMC Rheumatol. 2020;4:22.

Fundoscopic photograph used with permission from Jiang Y, et al. BMC Ophthalmol. 2018;18(1):11.

Skin image used with permission from Pattanaprichakul P, et al. Dermatol Pract Concept. 2014;4(4):33-35.

REFERENCES

  1. Edwards NL. Primer on the Rheumatic Diseases. 13th ed. New York, NY:Springer;2008:241-249.
  2. Choi HK, et al. Ann Rheum Dis. 2009;68:1609-1612.
  3. Doghramji PP, et al. Postgrad Med. 2012;124:98-109.