Bansal Pankaj (Orcid ID: 0000-0001-6315-6879)

Title Page

Title:
Rice Bodies in Pseudogout

Article type:
Clinical Images

Author names:
Pankaj Bansal, MD1,2

Corresponding author:
Pankaj Bansal, MD1,2

Author affiliations:
1: Athena Medical, Rheumatology. 1020 W Oak St, Kissimmee, FL 34741
2: Mayo Clinic Health System. 1400 Bellinger Street, Eau Claire, WI – 54701. bansal.pankaj@mayo.edu,
ORCID ID 0000-0001-6315-6879

Funding information:
All authors declare no competing interests and none of the authors have any financial interests which
could create a potential conflict of interest or the appearance of a conflict of interest with regard to the
work presented in this manuscript. There was no funding for the work associated with this publication.
None of the authors have been paid by any agency or pharmaceutical company to write this article. All
authors have full access to the manuscript and all the data in the study, contributed to the study design,
critically reviewed the first draft, approved the final version, and agreed to be accountable for the work,
and the corresponding author has the final responsibility for the decision to submit for publication.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/art.42542
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Rice bodies in pseudogout

77-years-old Hispanic female with past history of hyperlipidemia, hypertension, asthma, and
osteoarthritis of the knees presented with non-traumatic left knee pain, swelling and redness of 6-week
duration. On exam, she had erythema, effusion, warmth, and decreased range of motion of the left
knee. Rest of the history and exam were unremarkable. Gray mode sonography of the left knee revealed
a large suprapatellar effusion (★) with many hypo to hyperechoic oval and round structures in the
synovium (*), compatible with rice bodies. (Figure 1,2. F: Femur. Q: Quadriceps tendon. P: Patella. T:
Tibia.) On the medial and lateral longitudinal views, there were large osteophytes (white arrow) along
with calcification of the menisci (white arrowheads). (Figure 2) Synovial fluid aspiration revealed 4290
nucleated cells/mL, 64% neutrophils, and intracellular calcium pyrophosphate crystals. Laboratory
workup was significant for elevated C-reactive protein at 24.1 mg/L and negative antinuclear antibody,
rheumatoid factor and anti-cyclic citrullinated peptide antibodies. Radiographs revealed
chondrocalcinosis of the menisci (white arrowheads) and osteoarthritic changes but no erosions. (Figure
3) The patient was treated with colchicine 0.6mg twice daily and intra-articular 40mg depomedrol
injection leading to resolution of symptoms at 4-week follow-up.

Rice bodies can be seen in the joints, bursae or tenosynovium, and appear as 3mm-7mm bodies that
macroscopically resemble polished grains of white rice. Sonographically, they appear as hypo to hyper
echoic well-defined round or oval bodies. (1) They have mostly been identified in infections such as
tuberculosis and inflammatory arthropathies including rheumatoid arthritis and psoriatic arthritis
although have not been reported in association with pseudogout to our knowledge. (1,2)The proposed
mechanisms for formation of rice bodies in pseudogout would be similar to any other inflammatory
arthropathy, and includes inflammation, synovial proliferation and degeneration, tissue ischemia and
fibrin encapsulation. (3) Treatment of underlying inflammatory process is the cornerstone for
management, although lavage and aspiration, synovectomy or fibrinolytics such as urokinase can be
electively used.

REFERENCES
1. Keshavamurthy C, Bansal P. Clinical Images: Rice bodies in subacromial bursa at initial presentation of
rheumatoid arthritis. ACR Open Rheumatol 2022;4:802–803.

2. Kahn M, Fleece M. Rice Bodies in Tenosynovitis Due to Psoriatic Arthritis. N Engl J Med 2022;387:e14.

3. Law TC, Chong SF, Lu PP, Mak KH. Bilateral subacromial bursitis with macroscopic rice bodies:
ultrasound, CT and MR appearance. Australas Radiol 1998;42:161–163.
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