MR imaging is not routinely used for evaluation of tophaceous gout. However, gout may present clinically in an atypical, unusual, or confusing manner. A gouty tophus occasionally mimics an infectious or neoplastic process, and MR imaging may be obtained under these circumstances. The purpose of this study was to determine the MR imaging characteristics of intraosseous and soft-tissue tophi.

We identified 13 MR imaging examinations performed during a 27-month period on nine patients with gouty arthritis. All were men 42-70 years old. T1-, proton density-, and T2-weighted spin-echo MR images were obtained for all the examinations. Nine examinations included contrast-enhanced MR images. The findings were then evaluated, as were the corresponding radiographs.

Five patients presented with articular involvement, three patients with an isolated soft-tissue mass, and one patient with persistent soft-tissue swelling. The duration of symptoms ranged from 3 months to more than 20 years. Nearly all the tophi were of intermediate signal intensity on T1-weighted images. On T2-weighted images, three sites revealed an overall increase in the signal intensity of the tophi, whereas 10 studies showed a heterogeneous decrease in signal intensity. All but one tophus showed homogeneous enhancement. Erosion of adjacent bone, synovial pannus, joint effusion, soft-tissue edema, and bone marrow edema were common associated findings.

The MR appearance of tophi in patients with tophaceous gout is constant on T1- but quite variable on T2-weighted images. This variability in signal intensity could be related to calcium within a tophus. Tophaceous gout should be considered in the differential diagnosis when a mass reveals heterogeneously low to intermediate signal intensity, particularly if the adjacent bone shows typical erosive changes or if other joints are involved. When faced with this situation, radiologists may find it helpful to obtain a further clinical history and recommend evaluating the patient's serum urate level.