Magnetic resonance imaging in Tietze’s syndrome L. Volterrani1, M.A. Mazzei2, N. Giordano3, R. Nuti3, M. Galeazzi4, A. Fioravanti4 1Department of Human Pathology and Oncology, 3Department of Internal Medicine, and 4Rheumatology Unit, Department of Clinical and Immunological Science, University of Siena, Siena, Italy; 2Radiologia Universitaria, Policlinico Santa Maria alle Scotte, Azienda Ospedaliera Universitaria Senese, Siena, Italy. Abstract Objective To evaluate the usefulness of magnetic resonance imaging (MRI) in Tietze’s syndromesyndrome which,which, toto ourour knowledge,knowledge, hashas notnot previously been reported in the literature. Methods Twelve consecutive outpatients with clinical features of Tietze’s syndromesyndrome underwentunderwent evaluation,evaluation, includingincluding tthehe aanamnesis,namnesis, clinical general examination, clinical evaluation of costosternal and sternoclavicular joints (SCJ) and biochemical and instrumental investigations. Twenty normal subjects age- and sex-matched to the patients’ groupgroup werewere examined in a similar manner. MRI of costosternal and SCJ was performed using a 1.5 Tesla unit (Gyroscan NT 1.5 Philips, The Netherlands and GE Signa Excite HD, GE Healthcare, Milwaukee, Wis., USA). Results The MRI pattern of primary Tietze’s syndromesyndrome waswas characterizedcharacterized asas follows:follows: enlargementenlargement andand thickeningthickening ooff ccartilageartilage aatt the site of complaint (12/12 patients); focal or widespread increased signal intensities of affected cartilage on both TSE T2-weighted and STIR or FAT SAT images (10/12 patients); bone marrow oedema in the subcondral bone (5/12 patients); vivid gadolinium uptake in the areas of thickened cartilage, in the subcondral bone marrow and/or in capsule and ligaments (10/12, 4/12 and 7/12 patients respectively). Conclusion Magnetic resonance is an excellent technique to evidence both the cartilage and bone abnormalities, therefore it represents the elective method in the investigation of primary Tietze’s syndrome,syndrome, duedue toto itsits highhigh sensitivity,sensitivity, ddiagnosticiagnostic rreliabilityeliability aandnd biological advantages thanks to the lack of ionizing radiation. Key words Tietze’s syndrome, magnetic resonance imaging, diagnosis, costosternal joints, sternoclavicular joints. Clinical and Experimental Rheumatology 2008; 26: 848-853. MRI in Tietze’s sindrome / L. Volterrani et al. Luca Volterrani, MD, Prof. of Radiology Introduction to evaluate the usefulness of MR in the Maria Antonietta Mazzei, MD Named in 1921 after Alexander Tietze, diagnosis of Tietze’s syndrome which, Nicola Giordano, MD, Prof. of Rheumatology a German surgeon (1), Tietze’s syn- to our knowledge, has not previously Ranuccio Nuti, MD, Prof. of Int. Medicine drome, also known as costochondritis, been reported in the literature. Mauro Galeazzi, MD, Prof. of Rheumatology Antonella Fioravanti, MD is an infl ammatory process involv- ing one or more of the costochondral Patients and methods Please address correspondence and reprint requests to: cartilages. Tietze’s syndrome can be Between July 2004 and December Dr. Maria Antonietta Mazzei, defi ned as a benign, painful, non-sup- 2006, 12 consecutive outpatients (ten Radiologia Universitaria, purative, with localised swelling of women and two men, mean age 56.08 Policlinico Santa Maria alle Scotte, the costosternal, costochondral, and/or years, age range 29 to 70 years) with Azienda Ospedaliera Universitaria Senese, sternoclavicular joints (SCJ) (Tietze’s Tietze’s syndrome were observed at the Viale Bracci 2, Siena 53100, Italy. area), in the absence of other causes Rheumatology Unit (A. F. and M. G.) E-mail: [email protected] which could be responsible for this dis- and the Department of Internal Medi- Received on July 26, 2007; accepted in order (1, 2). In most cases (80%), only cine (N.G. and R.N.) of the University revised form on March 19, 2008. one costal cartilage is involved (most of Siena. The demographic data and © CopyrightCopyright CLINICAL AND commonly the second or the third rib), clinical characteristics of the patients EXPERIMENTAL RHEUMATOLOGY 2008.2008. but other joints can be affected simul- are summarized in Table I. The same taneously (2, 3). The exact occurrence rheumatologist performed patients’ of this condition is not well known. It evaluation, including the medical his- predominantly strikes subjects between tory, general examination and clinical twenty and fi fty years of age, even if evaluation of costosternal joints and cases in children and the elderly have SCJ. All the subjects examined had no been documented (3, 4). Moreover, it history of thoracic trauma, aggressive has been reported that females are di- exercise able to cause strain, prior up- agnosed with the disease more often per respiratory tract infection, or either than males by a 2:1 ratio (2). The ae- signs and/or symptoms of systemic dis- tiopathogenesis of Tietze’s syndrome ease. Furthermore, a series of labora- is still being debated: the micro-trau- tory exams including blood cell count, matic theory currently seems to be the erythrocyte sedimentation rate, C-re- most cited one (3, 5, 6). Histological active protein, serum uric acid, lactate examinations of the swellings showed dehydrogenase, creatine phosphoki- non-specifi c fi ndings in the hyaline nase (CPK), CPK-MB, troponin, rheu- cartilage, consisting of an increased matoid factor, anti-cyclic citrullinated vascularity and degenerative changes peptide antibodies and urinalysis were with patchy loss of ground substance performed. Bacterial, viral, and my- leading to a fi brillar appearance (7). cotic cultures of blood, sputum, urine Different rheumatic and non-rheumatic and stools were also collected, in order diseases can account for pain with or to exclude other pathologies. Finally, without swelling around Tietze’s area chest x-rays and electrocardiograms (8-15). The diagnosis of this condition (ECG) were recorded for all patients. is primarily clinical. Many radiologi- During the same period, 20 normal sub- cal techniques have been suggested to jects, age and sex matched, were exam- confi rm the diagnosis, but there are few ined in a similar manner. The study was studies on the value of conventional ra- approved by the Ethics Committee of diography (16, 17), computed tomog- the School of Medicine of the Univer- raphy (CT) (18, 19), scintigraphy with sity of Siena. All patients provided in- 67Ga and 99mTc diphosphonate (20, formed oral consent. In all the individ- 21), and ultrasound (US) (22-25). Mag- uals examined, an MR imaging of the netic resonance (MR) (26) is an excel- anterior thoracic wall was performed lent technique to show cartilaginous, by using a 1.5 Tesla unit (Gyroscan joints and bone abnormalities: it has NT 1.5 Philips, The Netherlands and been employed in cases of chest wall GE Signa Excite HD, GE Healthcare, pain following thoracic trauma (27), Milwaukee, Wis.) with a superfi cial spondyloarthropathies (28), septic ar- and phased array detection receiving thritis and malignant tumours (26, 29), coil. Subjects were placed prone on the which may mimic Tietze’s syndrome. MRI table to reduce respiratory mo- Competing interests: none declared. The purpose of the present study was tion artefacts, arms alongside the body. 849 MRI in Tietze’s sindrome / L. Volterrani et al. Table I. Demographic data and clinical features of patients with Tietze’s syndrome. T2-weighted images) compared with the normal bone signal intensity, and Patient Age (year)/sex Duration of Clinical fi ndings Tietze’s syndrome, capsular and ligament involvement. when fi rst examined The criterion for diagnosis of cartilage (years) enlargement used was represented by the thickened and bulbous aspect of the 1 70/F 2 Painful tender swelling of the right SCJ 2 62/F 0.6 Painful swelling of the right SCJ affected tissue compared to the oppo- 3 56/F 1.6 Painful swelling of either SCJ site normal side (18). The enhancement 4 62/F 3 Painful swelling at left fi rst costochondral junction characteristics of the abnormal tissue 5 64/F 1.5 Painful swelling of either SCJ after gadolinium-based contrast mate- 6 56/F 2.3 Painful swelling of the right SCJ rial injections were also evaluated. The 7 58/F 0.6 Painful swelling of the right SCJ fi nal decision regarding MR morphol- 8 42/M 0.8 Painful of the left third costochondral junction ogy as well as MR signal characteristics 9 58/F 0.8 Painful of the left SCJ and enhancement of the cartilaginous, 10 29/F 1 Painful swelling at right third costochondral junc- bone and joint components was done by tion 11 56/F 0.6 Painful tender swelling of the right SCJ consensus. 12 60/M 1.8 Painful swelling of the right second costochondral junction Results Biochemical parameters, chest x-rays In the pre-contrast examination, fast were taken for all patients examined and electrocardiogram appeared within spin-echo T1-weighted (FSE T1) on on the Gyroscan MR unit. The princi- the normal limits for both patients and axial or coronal planes, fast spin-echo pal data of the MR sequences used are control subjects; cultures also gave neg- T2-weighted (FSE T2) and T2 STIR reported in Table II. The MR images ative results in patients and controls. (short time inversion recovery) or FAT were evaluated by two experienced SAT (saturation) sequences on coronal musculoskeletal radiologists (L.V. and Normal subjects planes were chosen. For all sequences, M.A.M.). The following MR imag- Among the 20 normal subjects exam- slice thickness