Dual-Energy CT Diagnosis of Gouty Arthritis in the Foot

Cleveland Clinic Abu Dhabi, UAE
By Dr. Esat Memisoglu, MD.
Jorge Guerra RT
Lynda Sullivan RT
Imaging Institute, Cleveland Clinic Abu Dhabi
Dr. Abhay Joshi, MD.
Rheumatology, Cleveland Clinic Abu Dhabi

A 49 year old male patient with past history of skin psoriasis and hyperuricemia complains of recurrent bilateral knee, ankle and foot pain. He appears to have bilateral patellofemoral osteoarthritis and has no family history of gout. There is suspicion of psoriatic arthritis versus gout. Further investigation with Dual-Energy CT (DECT) was requested to look for uric acid crystals.

Non-contrast DECT scan of the feet was performed. Standard bone window and color rendered multi planar
reconstructed images as well as 3D volume rendering were obtained using the syngo.via DECT gout application.
Monosodium Urate (MSU) deposition was coded green in the color maps.

DECT images disclosed extensive bone erosions and MSU deposition with calcifications in the periarticular soft tissues and tendons.

There are striking juxta-articular erosions involving the right first MTP joint, left second MTP joint, intertarsal and tarsometatarsal joints and right lateral malleolus demonstrating overhanging edges and sclerotic margins. 
Secondary osteoarthritic changes are seen as well. The adjacent areas of calcific soft tissue tophi demonstrate green color labeling, consistent with MSU crystal deposition. Calcification in tophi is due to coexisting calcium pyrophosphate crystals. Diffuse bilateral anterior tibial tendon thickening is also seen with multifocal green color deposits, consistent with intratendinous gout.

Gout is a painful and potentially debilitating condition. Definitive diagnosis of gout has been historically achieved with aspiration of synovial fluid from an affected joint to look for urate crystals. This however is an invasive procedure which sometimes can yield false negative results. Dual-Energy Computed Tomography (DECT) could essentially change the diagnostic approach to tophaceous and non-tophaceous gout, facilitating a rapid and accurate noninvasive examination. This can also be helpful in anatomic areas where aspiration can be challenging to perform. The chemical composition of uric acid lends itself to behave differently with varying energy x-ray spectra.
Simultaneous DECT acquisition of high and low energy datasets in a single scan and further auto post-processing with syngo.via workstation allow visualization of MSU deposition in color coded maps.


SOMATOM Definition flash



Scan area

Both foot

Rotation time

0.33 s

Scan mode

DECT –Dual energy



Scan length

232 mm

Slice collimation

64 × 0.6 mm

Scan direction


Slice width

1 mm

Scan time

5.6 s

Reconstruction increment

0.5 mm

Tube voltage

80 kv / sn 140 kv

Reconstruction kernel


Effective mAs

225 mAs

SAFIRE Strength


Dose modulation


Effective dose

2.98 mSv


10.51 mGy


213 mGy

The outcomes by Siemens Healthineers customers described herein are based in results that were achieved in the customer’s unique setting. Since there is no ”typical” hospital and many variables exist (e.g. Hospital size, case mix, level of IT adoption), there can be no guarantee that other customers will achieve the same results.

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