Ultrasound Can Reveal Renal Medulla Urate Deposits in Tophaceous Gout


Tophaceous gout is chronic form of gout. Nodular masses of uric acid crystals (tophi) are deposited in different soft tissue areas of the body. Even though tophi are most commonly found as hard nodules around the fingers, at the tips of the elbows, and around the big toe, tophi nodules can appear anywhere in the body.

Ultrasound examination can be used to accurately reveal monosodium urate crystal deposits in the renal medulla of patients suffering from severe tophaceous gout.

This report describes the use of dual-energy CT scans and ultrasonography to reveal widespread crystal deposition in the renal medulla of 2 patients with severe gout. Patient 1, a 50-year-old French man with severe tophaceous gout and frequent flares, was poorly adherent to urate-lowering medications. A CT scan of his lower back due to persistent lower back pain revealed urate deposits in his intervertebral discs and renal medulla. Doctors then performed a renal ultrasound, which revealed normal cortical echogenicity and renal size but strong hyperechogenicity with massive acoustic shadowing on both medulla. On Doppler mode, doctors also saw twinkling artefacts typical for microcrystalline deposits.

Patient 2, a 40-year-old Vietnamese man who experienced his first gout flare in 2014 and his first tophus in 2015, had never received urate-lowering medications as of June 2018, despite reporting a number of acute flares per month.

The CT scan and radiographs showed dense crystal deposits in the medulla, and ultrasonography showed reduced kidney length and a strongly hyperechogenic medulla with numerous twinkling artefacts and posterior acoustic shadowing.

Study investigators conclude that [ultrasound] examination, which is cheaper and more available than [dual-energy] CT, is routinely used to look for urinary stones in gout. These two cases show that [ultrasound] examination can also be used to detect crystal deposition in the renal medulla, a classical but somewhat forgotten feature of the gouty kidney.


Bardin T, Tran KM, Nguyen QD, et al. Renal medulla in severe gout: typical findings on ultrasonography and dual-energy CT study in two patients. Ann Rheum Dis. 2018 Sep 29. pii: annrheumdis-2018-214174. doi: 10.1136/annrheumdis-2018-214174