Letter

Ann Rheum Dis: first published as 10.1136/annrheumdis-2018-214174 on 29 September 2018. Downloaded from http://ard.bmj.com/ on 1 October 2018 by guest. Protected by copyright.
Renal medulla in severe gout: typical findings
on ultrasonography and dual-energy CT study in
two patients

Monosodium urate (MSU) crystal deposition in renal medulla,

described as early as the 1800s,1 was documented by autopsy
studies in the 1950s to 1970s,2 3 and later by renal biopsies.4
Renal deposits have been reported mainly in patients with gout
and rarely in non-gout patients with renal failure.4 Deposits
appeared to be surrounded by inflammatory granulomas and
medullary fibrosis. These observations led to the description
of microcrystalline gouty nephropathy, a concept that was
later challenged and even denied.5
Here, we report on two patients with severe gout and the Figure 2  Patient 2. US study shows intensively hyperechoic medulla,
use of modern imaging modalities to reveal widespread crystal with posterior acoustic shadowing (A) and twinkling artefacts (B).
deposition in the renal medulla. Abdominal radiography (C) and CT scan (D) show several foci of high
Patient 1 was a French 54-year-old man with Lesch– density in renal medullae, consisting of red-coded urate on DECT (E).
Nyhan syndrome; the gene defect was previously reported.6 DECT, Dual-energy CT; US, ultrasonography.
The patient experienced several episodes of renal colic and
had severe tophaceous gout, frequent flares, urate arthrop-
not dilatated. The resistive index calculated at the level of the
athies and worsening dystonia. He was poorly adherent to
interlobar arteries was not elevated (mean 0.72 and 0.73), but
urate-lowering drugs, and the uricaemia fluctuated over the
medulla stiffness, measured by real-time shear wave elastog-
years from rarely normal to frequently high (10–15 mg/dL).
raphy, was strongly increased to 45 kPa as compared with the
The patient took a beta-blocker for hypertension; the body
cortex (mean 20 kPa).
mass index (BMI) was 29 kg/m2. In 2018, the serum uric acid
Patient 2 was a 40-year-old Vietnamese man who under-
level was 3.4 mg/dL (under febuxostat treatment 240 mg/day),
went surgical ablation of a renal stone in 2013; he experienced
creatinine level 114 mmol/L, and estimated glomerular filtra-
a first gout flare in 2014, and the first tophus appeared in
tion rate 58 mL/min/1.73 m2 by the Modification of Diet in
2015. As of June 2018, he had never received urate-lowering
Renal Disease (MDRD) formula. Urine lab stick examination
drugs and reported several acute flares each month. He had
revealed no proteinuria, haematuria or leucocyturia and pH
a large tophus at the lateral aspect of the right ankle and a
6.4. Dual-energy CT (DECT; Aquilion PRIME, Canon, Japan)
first metatarsophalangeal urate arthropathy. The gout diag-
of the lumbar back performed because of persistent low back
nosis was confirmed by the observation of MSU crystals in
pain revealed urate deposits in intervertebral discs and the
tophus aspirate and double contours of the two first meta-
renal medulla (figure 1). Renal ultrasonography (US) revealed
tarsophalangeals on US. The patient had no comorbidities
normal renal size (length 116 and 110 mm) and normal cortical
except untreated hypertriglyceridemia (5.43 mmol/L). BMI
echogenicity; both medullae exhibited a hyperechoic pattern
was 20 kg/m2. Serum uric acid level was 8.5 mg/dL, serum
of all Malpighi pyramids with massive acoustic shadowing.
creatinine level 281.5 mmol/L and glomerular filtration rate
The presence of twinkling artefacts on colour-Doppler US was
(estimated by MDRD) 24 mL/min/1.73 m2. Urine lab stick
typical for microcrystalline deposits (figure 1). No renal stone
showed 3+leucocyturia, 2+proteinuria and pH 6.5. Polar-
was detected in the renal sinus, and the pelvicalyceal tree was
ising light examination showed no crystallinuria. US examina-
tion revealed reduced length of kidneys (97 and 98 mm) with
irregular contours. The medulla was strongly hyperechogenic,
with posterior acoustic shadowing and numerous twinkling
artefacts figure 2. No sinus stone was seen. Resistive index
values were normal (0.71 and 0.73). Radiographs and CT scan
showed dense deposits in the medulla, which appeared to be
mainly composed of urate on DECT analysis (figure 2).
Our report shows that modern imaging techniques can
reveal urate deposits in the renal medulla of patients with
severe tophaceous gout. US examination, which is cheaper
and more available than DECT, is routinely used to look for
urinary stones in gout. These two cases show that US exam-
ination can also be used to detect crystal deposition in the
renal medulla, a classical but somewhat forgotten feature of
the gouty kidney.

Thomas Bardin,1,2,3 Khoi Minh Tran,1 Quang Dinh Nguyen,1

Figure 1  Patient 1. US shows strong hyperechogenicity of the renal Marine Sarfati,2 Pascal Richette,2,3 Nhan Thanh Vo, Valérie Bousson,4,5
medulla on B mode (A), with twinkling artefacts behind reflecting Jean-Michel Correas6,7
interfaces on Doppler mode (B). On CT scan (C), dense deposits are seen 1
French-Vietnamese Research Center on Gout and Chronic diseases, Vien Gut
in the medulla, which seems to be composed of red-coded urate on Medical Clinic, Ho Chi Minh City, Vietnam
2
DECT (D,E). DECT, Dual-energy CT; US, ultrasonography. Rheumatology Department, Hôpital Lariboisière APHP, Paris, France

Ann Rheum Dis Month 2018 Vol 0 No 0    1

Letter

Ann Rheum Dis: first published as 10.1136/annrheumdis-2018-214174 on 29 September 2018. Downloaded from http://ard.bmj.com/ on 1 October 2018 by guest. Protected by copyright.
3
Université Paris Diderot, INSERM U1132, Paris, France © Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and
4
Université Paris Diderot, CNRS UMR 7052, Paris, France permissions. Published by BMJ.
5
Radiology Department, Hôpital Lariboisière APHP, Paris, France
6
Radiology Department, Hôpital Necker APHP, Paris, France
7
Paris Descartes University, Paris, France
Correspondence to Professor Thomas Bardin, Service de Rhumatologie, Hôpital To cite Bardin T, Tran KM, Nguyen QD, et al. Ann Rheum Dis Epub ahead of print:
Lariboisière, Paris 75010, France; ​thomas.​bardin@a​ php.​fr [please include Day Month Year]. doi:10.1136/annrheumdis-2018-214174

Received 24 July 2018

Handling editor  Josef S Smolen Revised 5 September 2018
Contributors  TB was involved in the two patient care, conceived this report Accepted 7 September 2018
and wrote the manuscript draft. TMK performed the US study in HCMC. MS was Ann Rheum Dis 2018;0:1–2. doi:10.1136/annrheumdis-2018-214174
involved in the first patient care and retrieved data from his file. NTV performed the
DECT examination of the second patient. VB performed the DECT scan of the first
patient. J-MC performed the US study of the first patients. All authors improved the References
manuscript and approved its final version. 1 Garrod A. La goutte, sa nature, son traitement et le rhumatisme goutteux,
translatedand annotated by J. M. Charcot. Paris: Adrien Delahaye, 1867.
Competing interests  None declared. 2 Brown J, Mallory GK. Renal changes in gout. N Engl J Med 1950;243:325–9.
Patient consent  Obtained. 3 Talbott JH, Terplan KL. The kidney in gout. Medicine 1960;39:469–526.
4 Linnane JW, Burry AF, Emmerson BT. Urate deposits in the renal medulla. Prevalence
Provenance and peer review  Not commissioned; externally peer reviewed. and associations. Nephron 1981;29(5-6):206–22.
Author note  This letter provides the first evidence of urate crystal deposition in the 5 Beck LH. Requiem for gouty nephropathy. Kidney Int 1986;30:280–7.
renal medulla in severe gout patients by modern Imaging modalities and suggests 6 Ea HK, Bardin T, Jinnah HA, et al. Severe gouty arthritis and mild neurologic
that US should be used to look not only for urinary stones, but also for medullary symptoms due to F199C, a newly identified variant of the hypoxanthine guanine
crystal deposits phosphoribosyltransferase. Arthritis Rheum 2009;60:2201–4.

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