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whilst liver and kidney functions were normal&#46; Since that time the patient has attended check-ups with great irregularity and is treated with anti-inflammatory drugs and a 15&#8211;30<span class="elsevierStyleHsp" style=""></span>mg&#47;day dose of prednisone&#44; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;day dose of colchincine and 300<span class="elsevierStyleHsp" style=""></span>mg&#47;day dose of allopurinol according to his own criteria&#46; In 2011 he started treatment with febuxostat&#44; which he takes inconsistently&#46; In 2012 he was operated on in another hospital for articular retraction of the fifth finger and carpal tunnel syndrome due to tophaceous material&#46; In 2013&#44; amputation of the distal phalanx of the second finger on the right hand was performed due to epidermoid carcinoma&#46; In 2014&#44; he suffered a transient ischaemic attack due to complete thrombosis-occlusion of the right internal carotid artery&#46; In 2015 the patient presented with omalgia of the right shoulder of 4 month onset when making certain movements and when lying down on his side at night&#46; Examination revealed limitation in the last degrees of internal rotation and active and passive abduction&#46; Plain X-ray was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41; and magnetic resonance &#40;MR&#41; of the right shoulder &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;<span class="elsevierStyleSmallCaps">C</span>&#41; with analgesic treatment leading to an improvement in clinical symptoms&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The presence of tophaceous gout is correlated with persistence over time of hyperuricaemia and&#47;or ineffective treatment&#46; Tophi deposits have been described in many atypical locations&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> but of these the glenohumeral joint is rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a> The first description was made by O&#8217;Leary&#44; when the tophi were observed after performing an arthroscopy as they had not been detected in the MR&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Radiologic characteristics of tophi include erosions with well defined margins&#44; preservation of joint space and dense nodules of soft tissues which are sometimes calcified&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Ultrasound scan is more sensitive and specific for the detection of microcrystalline deposits in bursae&#44; tendons&#44; ligaments and soft tissues&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Double energy computerised tomography &#40;DECT&#41; is also used for the detection and measurement of tophi in unusual locations or when they mimic infection or malignancy&#44; as 3d reconstruction of images is enabled&#46; The highest limitation is radiation and its use in major joints such as the shoulder and hip&#44; where precision is lost&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> MR provides information for deep tissue joints and for intraosseous deposits&#44; but although it is highly sensitive for detection&#44; the tophi offer a non specific pattern similar to other soft tissue masses&#44; with low intensive signalling in T1 and variable intensity in T2&#46; As a result the patient&#39;s medical history is required for accurate diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical Liabilities</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of people and animals</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors declare that for this research no experimentation has been carried out on human beings or animals&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Data confidentiality</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that they have adhered to the protocol of their centre of work on the publication of patient data&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and&#47;or subjects referred to in this article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of Interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Images in Clinical Rheumatology
Tophaceous Gout of the Shoulder Joint
Afectación del hombro en la gota tofácea
Ana María Tierra Rodriguezb, Lucía Pantoja Zarzaa,
Corresponding author
lpantojazarza@gmail.com

Corresponding author.
, Pelayo Brañanova Lópezc, Carolina Diez Morrondoa
a Unidad Reumatología, Hospital El Bierzo, Ponferrada, León, Spain
b Servicio Medicina Interna, Hospital El Bierzo, Ponferrada, León, Spain
c Servicio Radiodiagnóstico, Hospital El Bierzo, Ponferrada, León, Spain
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              "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#41; Imagen por RM de hombro derecho en adquisici&#243;n coronal en secuencia potenciada en T1&#46; En una imagen superponible a la radiograf&#237;a de la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> B se observan los tofos como masas de tejidos blandos hipointensas en T1 en el borde superior del extremo clavicular distal &#40;1&#41; y en la bursa subacromiodeltoidea &#40;2&#41;&#46; B&#41; Imagen en adquisici&#243;n axial T2 eco de gradiente&#46; La RM revela una lesi&#243;n compatible con tofo gotoso &#40;1&#41; en el borde articular glenohumeral no claramente visible en la radiograf&#237;a simple&#46; Es hiperintenso en secuencia potenciada en T2&#44; interrumpe la corteza &#243;sea y tiene un reborde muy hipointenso por la esclerosis &#243;sea &#40;2&#41;&#46; Se asocia un discreto derrame synovial &#40;3&#41;&#46; C&#41; Imagen en adquisici&#243;n sagital en densidad prot&#243;nica que permite ver la secci&#243;n de los tendones que forman en manguito de los rotadores&#58; redondo menor &#40;1&#41;&#44; infraespinoso &#40;2&#41;&#44; supraespinoso &#40;3&#41; y subescapular &#40;4&#41;&#46; El supraespinoso est&#225; especialmente desestructurado por la presencia de un n&#243;dulo sugestivo de tofo intratendinoso &#40;&#42;&#41;&#46; Como en la secuencia potenciada en T2&#44; el tofo &#243;seo es hiperintenso &#40;5&#41;&#46;</p>"
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whilst liver and kidney functions were normal&#46; Since that time the patient has attended check-ups with great irregularity and is treated with anti-inflammatory drugs and a 15&#8211;30<span class="elsevierStyleHsp" style=""></span>mg&#47;day dose of prednisone&#44; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;day dose of colchincine and 300<span class="elsevierStyleHsp" style=""></span>mg&#47;day dose of allopurinol according to his own criteria&#46; In 2011 he started treatment with febuxostat&#44; which he takes inconsistently&#46; In 2012 he was operated on in another hospital for articular retraction of the fifth finger and carpal tunnel syndrome due to tophaceous material&#46; In 2013&#44; amputation of the distal phalanx of the second finger on the right hand was performed due to epidermoid carcinoma&#46; In 2014&#44; he suffered a transient ischaemic attack due to complete thrombosis-occlusion of the right internal carotid artery&#46; In 2015 the patient presented with omalgia of the right shoulder of 4 month onset when making certain movements and when lying down on his side at night&#46; Examination revealed limitation in the last degrees of internal rotation and active and passive abduction&#46; Plain X-ray was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41; and magnetic resonance &#40;MR&#41; of the right shoulder &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;<span class="elsevierStyleSmallCaps">C</span>&#41; with analgesic treatment leading to an improvement in clinical symptoms&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The presence of tophaceous gout is correlated with persistence over time of hyperuricaemia and&#47;or ineffective treatment&#46; Tophi deposits have been described in many atypical locations&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> but of these the glenohumeral joint is rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a> The first description was made by O&#8217;Leary&#44; when the tophi were observed after performing an arthroscopy as they had not been detected in the MR&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Radiologic characteristics of tophi include erosions with well defined margins&#44; preservation of joint space and dense nodules of soft tissues which are sometimes calcified&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Ultrasound scan is more sensitive and specific for the detection of microcrystalline deposits in bursae&#44; tendons&#44; ligaments and soft tissues&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Double energy computerised tomography &#40;DECT&#41; is also used for the detection and measurement of tophi in unusual locations or when they mimic infection or malignancy&#44; as 3d reconstruction of images is enabled&#46; The highest limitation is radiation and its use in major joints such as the shoulder and hip&#44; where precision is lost&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> MR provides information for deep tissue joints and for intraosseous deposits&#44; but although it is highly sensitive for detection&#44; the tophi offer a non specific pattern similar to other soft tissue masses&#44; with low intensive signalling in T1 and variable intensity in T2&#46; As a result the patient&#39;s medical history is required for accurate diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical Liabilities</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of people and animals</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors declare that for this research no experimentation has been carried out on human beings or animals&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Data confidentiality</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that they have adhered to the protocol of their centre of work on the publication of patient data&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and&#47;or subjects referred to in this article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of Interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; MR image of the right shoulder in coronal plane in T1 weighted sequence&#46; In one image superimposed onto the X-ray of <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B we may observe the tophi as hypointense soft tissue masses in T1 along the upper ridge of the distal end of the clavicle &#40;1&#41; and in the subacromiodeltoid bursa &#40;2&#41;&#46; &#40;B&#41; Image in axial T2 gradient-echo plane&#46; The MR reveals a lesion compatible with gouty tophus &#40;1&#41; in the glenohumeral joint edge which is not clearly visible in plain X-ray&#46; It is hyperintense in T2 weighted sequence&#44; interrupts the bony cortex and has a highly hypointense ridge from bone sclerosis &#40;2&#41;&#46; Mild synovial effusion is present &#40;3&#41;&#46; &#40;C&#41; Proton density image in sagittal plane which enables vision of the section of the tendon which forms in the sleeve of the rotator cuffs&#58; teres menor &#40;1&#41;&#44; infraespinatus &#40;2&#41;&#44; supraespinatus &#40;3&#41; and subescapularis &#40;4&#41;&#46; The supraspinatus is particularly de-structured by the presence of a nodule suggestive of intratendinous tophus &#40;&#42;&#41;&#46; Similarly to the T2 weighted sequence&#44; the bony tophus is hyperintense &#40;5&#41;&#46;</p>"
        ]
      ]
    ]
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      "titulo" => "References"
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                            2 => "C&#46;W&#46; Yu"
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                        0 => array:2 [
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                  ]
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                          "etal" => true
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                            0 => "L&#46; Ventura-R&#237;os"
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ISSN: 21735743
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