Mr. MT, a 60-year-old Malay man, presented with right ankle and foot pain and swelling for 2 days. He has underlying multiple medical problems including diabetes mellitus, hypertension, and coronary artery disease with coronary artery bypass performed years ago. He was diagnosed as gouty arthritis before, but relatively symptom free without treatment for the past 6 years.
He travelled to Europe for a month and just came back 1 week prior to his clinic visit. He gave history of taking a lot of salmon while in Europe. He was relatively well during his journey.
He complained of right ankle and foot pain and swelling for 2 days and was referred to rheumatologist for acute gouty arthritis. He had low-grade fever. Other joints were normal. He took Colchicine several times before came to clinic. There’s not much improvement with Colchicine and in combination of other analgesia.
His right ankle was swollen, painful and warm on palpation. The range of movement markedly reduced due to pain. He was unable to bear weight and difficult to walk.
Blood test was performed and noted markedly elevated white blood count and C-reactive protein. Glucose and creatinine level were also high. Uric acid level was normal.
Musculoskeletal ultrasound was performed to look for any changes in gouty arthritis and to exclude septic arthritis.
Figure 1a
Figure 1b
Figure 1c
Figure 1a and b:
Ultrasound image of right ankle at tibio-talar joint in transverse view.
Image showed presence of marked synovial effusion in the anterior aspect of ankle joint. The effusion (*) appear as generalized anechoic without increase in power doppler flow (Fig. 1b)
Arrow in Fig. 1c showed presence of double contour sign, most likely due to urate crystal deposition on the articular cartilage surface indicating concomitant gouty arthritis.
TA- Tibialis Anterior tendon
EHL- Extensor Halucis Longus tendon
EDL- Extensor Digitorum Longus tendon
TAL- Talus bone
Figure 2a
Figure 2b
Figure 2c
Fig. 2a-2c:
Ultrasound images of right ankle joint in longitudinal view at tibio-talar (Fig 2a and 2c) and talo-fibular joint (Fig. 2b).
Images showed distention of the synovial joints with presence of synovial effusion (*) appear as anechoic and hypoechoic. There’s area of variable hyperechogenic debris seen especially in fig. 2b and 2c, which could represent microtophi or monosodium urates crystal aggregates. This also appear as 'snow storm' appearance in gouty arthritis
Arrow showed in fig. 2a and 2c, most likely due to concomitant presence of gouty arthritis.
Overlying subcutaneous oedema observed.
TIB- Tibia bone
TAL- Talus bone
FIB- Fibula
