skip to main content

Intercritical Gout Imaging — SCE Rheumatology MCQ

Instant feedback + full explanation. One question, done properly.

ModerateCrystal ArthropathyIntercritical Gout ImagingSCE Rheumatology

A 50-year-old man with established gout is currently asymptomatic between flares and is not receiving urate-lowering therapy. Ultrasound of his first metatarsophalangeal joint shows a double contour sign and an intra-articular tophus. What is the most appropriate interpretation of these findings?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — They show persistent monosodium urate deposition; the tophus is an indication to offer treat-to-target ULT.

The double contour sign represents crystal deposition over the surface of hyaline cartilage, while a sonographically defined tophus represents a larger monosodium urate deposit. These findings demonstrate persistent crystal burden during the intercritical period: absence of pain does not imply absence of disease. NICE recommends offering treat-to-target urate-lowering therapy to people with gout who have tophi. Ultrasound lesions are highly specific but not completely infallible, so they are better described as strong evidence of MSU deposition rather than equivalent to microscopic crystal identification in every context. CPPD may occasionally produce a pseudo-double-contour appearance, but the combination of established gout, a true double contour sign and a tophus favours gout. Osteoarthritis and normal variants do not explain this combination.

Reference: NICE. Gout: diagnosis and management (NG219), recommendations on imaging and 1.5.1 on urate-lowering therapy. 2022. https://www.nice.org.uk/guidance/ng219/chapter/Recommendations