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| PICTORIAL ESSAY |
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| Year : 2020 | Volume
: 28
| Issue : 3 | Page : 179-180 |
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Scruples over speckles
Benjamin Persons, Eugene Y Kissin
Division of Rheumatology, Boston University Medical Center, Boston, MA, USA
| Date of Submission | 19-Dec-2019 |
| Date of Decision | 11-Feb-2020 |
| Date of Acceptance | 14-Feb-2020 |
| Date of Web Publication | 25-May-2020 |
Correspondence Address:
Dr. Eugene Y Kissin
Boston University, 72 E Concord St., Evans 501, Boston, MA 02118
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JMU.JMU_122_19
The “snowstorm” sign refers to the ultrasound appearance of motile hyperechoic specks within synovial fluid and has been reported to have a high specificity for gout. We describe three additional etiologies commonly encountered in the rheumatology clinic that can produce a snowstorm: calcium pyrophosphate deposition disease, fibrin collections/rice bodies, and gas bubbles in viscous synovial fluid.
Keywords: Calcium pyrophosphate, gout, rice body, snowstorm
How to cite this article:
Persons B, Kissin EY. Scruples over speckles. J Med Ultrasound 2020;28:179-80 |
Monosodium urate (MSU) crystals deposited in the joints and soft tissues elicit the inflammatory reaction of gout, the most prevalent form of inflammatory arthritis. In addition to detecting MSU crystals on synovial aspiration, evidence for gouty arthritis can frequently be seen on radiographs and on ultrasound (US) joint imaging. US findings of gouty arthritis include the “double-contour” sign, which corresponds to the deposition of MSU crystals on the surface of hyaline cartilage, subclinical tophaceous deposits, and the “snowstorm” sign, where hyperechoic aggregates are seen as free-floating specks in synovial fluid.[1] Both recent meta-analyses and a large observational study find the snowstorm sign to have a specificity of 90% for gout.[2],[3],[4]
In the observational study done by Ogdie et al., however, note is made that the snowstorm sign can be seen in calcium pyrophosphate deposition (CPPD) disease as well.[4] This in mind, we would like to report an expanded list of conditions that can produce free-floating hyperechoic specks in synovial fluid. The figure below displays US images and resultant aspirates from four patients seen in clinic over a 1-month period whose joints had a snowstorm appearance on US. Images have been obtained using a GE Logiq e device with 12 L probe set at 12 MHz. Four different etiologies as confirmed by microscopy are identified: fibrin aggregates [Figure 1]a, gas bubbles [Figure 1]b, calcium pyrophosphate crystals [Figure 1]c, and MSU crystals [Figure 1]d. | Figure 1: In each panel are displayed ultrasound image and corresponding joint aspirate with arrowheads indicating representative lesions. (a) Knee effusion, lateral transverse view, containing fibrin aggregates in a rheumatoid arthritis patient. (b) Posterior longitudinal view of popliteal cyst with hyperechoic specks due to gas bubbles suspended in viscous synovial fluid. (c) Posterior longitudinal view of popliteal cyst with calcium pyrophosphate aggregates. (d) Anterior longitudinal view of knee effusion from a patient with gout and hyperechoic specks due to monosodium urate crystals
Click here to view |
“Rice bodies” are collections of fibrin and leukocytes that are most commonly seen in rheumatoid arthritis but that have been linked to a variety of inflammatory joint conditions.[5] Befitting the name, the classic description has been of smooth, white granules that resemble rice, but intra-articular aggregates of fibrin come in a range of morphologies, some of which have previously been described as producing hyperechoic specks on US in a pattern similar to what we report.[6],[7]
The development of free-floating specks has also been reported under US after joint traction, commonly referred to as “knuckle cracking,” suggesting that manipulation is one process by which the development of intra-articular gas bubbles regularly occurs.[8],[9] Our experience suggests that bubbles can be seen in patients with osteoarthritis resulting in chronic effusions with very high viscosity as well.
As mentioned, CPPD is additionally known to manifest as synovial specks on ultrasound. In a meta-analysis of US findings in CPPD, 12% of descriptive terms reviewed are of intra-articular hyerechoic bodies or “spots without acoustic posterior shadowing,” which is similar to the 10% incidence of the snowstorm pattern for CPPD patients reported by Ogdie et al.[4],[10] These relatively common causes of mobile hyperechoic specks in synovial fluid should be considered before assuming that the snowstorm sign confirms a diagnosis of gout.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Filippucci E, Di Geso L, Grassi W. Tips and tricks to recognize microcrystalline arthritis. Rheumatology (Oxford) 2012;51 Suppl 7:vii18-21.  |
| 2. | Lee YH, Song GG. Diagnostic accuracy of ultrasound in patients with gout: A meta-analysis. Semin Arthritis Rheum 2018;47:703-9. |
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| 7. | Spence LD, Adams J, Gibbons D, Mason MD, Eustace S. Rice body formation in bicipito-radial bursitis: Ultrasound, CT, and MRI findings. Skeletal Radiol 1998;27:30-2. |
| 8. | Jones AR, Yelverton CJ, Bester C. Ultrasound imaging of the trapeziometacarpal articular cavity to investigate the presence of intraarticular gas bubbles after chiropractic manipulation. J Manipulative Physiol Ther 2014;37:476-84. |
| 9. | Malghem J, Omoumi P, Lecouvet FE, Vande Berg BC. Presumed intraarticular gas microbubbles resulting from a vacuum phenomenon: Visualization with ultrasonography as hyperechoic microfoci. Skeletal Radiol 2011;40:1287-93. |
| 10. | Filippou G, Adinolfi A, Iagnocco A, Filippucci E, Cimmino MA, Bertoldi I, et al. Ultrasound in the diagnosis of calcium pyrophosphate dihydrate deposition disease. A systematic literature review and a meta-analysis. Osteoarthritis Cartilage 2016;24:973-81. |
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