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290 a volume estimate and 3 ‐dimensional reconstruc‐ tion (FIGURE 1A –1D). The second patient was a 44 ‐year‐old man with ankylosing spondylitis diagnosed 2 years earlier, positive HLA‐B27 antigen, and typical inflamma‐ tory back pain, bilateral sacroiliitis documented on X‐rays, and recurrent acute peripheral (knee, ankle) arthritis. He was treated with sulfasala‐ zine and nonsteroidal anti ‐inflammatory drugs. The course of the disease was atypical, with sud‐ den‐onset symptoms (redness, swelling, and se‐ vere pain of affected joints). Laboratory tests re‐ vealed elevated serum uric acid concentrations of 13 mg/dl. We performed DECT, which showed areas of MSU deposits in the wrists, elbows, an‐ kles, and knees (FIGURE 1E). Therefore, coexisting gout was diagnosed and treatment with allopu‐ rinol and colchicine was introduced.1,2 Although identification of MSU crystals in sy‐ novial fluid or in soft tissue remains the gold stan‐ dard of gout diagnosis, DECT, as well as ultraso‐ nography and plain radiography, was included in the 2015 American College of Rheumatology/ Dual ‐energy computed tomography (DECT) is a novel technique that enables monosodium urate (MSU) crystal visualization and virtual imaging by acquiring 2 energy data sets. We had an opportu‐ nity to use this diagnostic technique in 2 differ‐ ent cases. The first case was a patient with an ag‐ gressive course of chronic tophaceous gout to as‐ sess the distribution of crystals and to monitor the effectiveness of treatment. The second case was a patient with a rare coexistence of gout and ankylosing spondylitis. The first patient was a 56 ‐year‐old man with gout diagnosed 30 years earlier. He presented with enormous tophi that deformed the upper and lower extremities, and with recurrent attacks of acute arthritis. Monosodium urate crystal de‐ posits ulcerated through the skin and formed numerous fistulas on the surface of the meta‐ carpophalangeal joints and lower extremities, with secondary Staphylococcus aureus infection. Small tophi formed also in the helix of the ears. The presence of MSU crystals was confirmed in the material obtained from the tophi. The serum uric acid concentration over the years was on av‐ erage 9 to 10 mg/dl, despite combined treatment with probenecid and febuxostat. The patient ex‐ perienced an allergic reaction to allopurinol. He was ineligible for surgical treatment due to in‐ fected skin ulcerations. Imaging examinations were performed to as‐ sess the degree of joint destruction. Plain radio‐ graph of the affected joints revealed soft tissue swelling with calcifications, periarticular osteopo‐ rosis, erosions, and destructive arthropathy. Ad‐ ditionally, DECT was performed, which showed massive aggregates of MSU in the elbow, hand, knee, and foot joints and in periarticular soft tissue, as well as calcifications. We also obtained CLINICAL IMAGE

Dual energy computed tomography – a novel imaging method on the two examples of a rare course of gout