Tietze's syndrome presenting as enthesitis diagnosed by ultrasound: A case report.

Tietze's syndrome (TS) is an inflammatory disorder characterised by painful, non-suppurative swelling in the sternocostal or sternoclavicular joint. The aetiology of TS is unknown. Herein, we described a case of isolated enthesitis in the sternocostal joint in a 42-year-old male patient whose clinical course led to the diagnosis of TS. A 42-year-old male Japanese patient (HLA-B27 negative) presented with chronic anterior chest wall pain. Mild swelling and tenderness were found in the right, third sternocostal joint (rt.3STCJ). No other arthralgia was present. Ultrasonography (US) of the rt.3STCJ showed hypoechoic thickening and power Doppler signal in the anterior radiate sternocostal ligament with mild synovial hypertrophy of the STCJ. US also depicted cortical bone erosion at the sternum with neovascularisation. Magnetic resonance imaging with T2-weighted short-tau inversion recovery showed high signal intensity in the bone marrow of the sternum and adjacent soft tissue around the rt.3STCJ. Based on these findings, TS with the enthesitis in the rt.3STCJ was diagnosed. The patient received a US-guided corticosteroid injection, and the symptoms completely resolved 10 months later. Enthesitis may cause TS. US is a readily available, sensitive imaging technique useful for diagnosing TS.

Immunopathological findings in a cat with auricular chondritis.

At clinical examination, a 5-year-old male domestic short-haired cat exhibited painful swelling and erythema of the pinnae of both ears. Microscopically, the lesions on both pinnae were composed of diffuse granulomatous chondritis with degeneration and necrosis of the pinnal cartilage. Numerous mast cells were also observed within and surrounding the inflammatory lesion. Immunohistochemistry showed a mixed inflammatory infiltrate characterised by the predominance of macrophages (CD68+, MAC 387+ and Lysozyme+), T lymphocytes (CD3+), some B lymphocytes (CD79α+) and neutrophils. Immunopathological characterisation of the lesion showed a granulomatous inflammation profile and suggests that the morphological changes and immunopathogenesis of auricular chondritis in cats presents a similarity with relapsing polychondritis in humans.

Surgical Management of Medically Refractory Tietze Syndrome.

Tietze syndrome is a rare and benign cause of chest pain that may be confused with life-threatening conditions. Characteristic findings are painful, localized inflammation of the costosternal, sternoclavicular, or costochondral joints typically of the second and third ribs. We present a patient with severe, medically refractory symptoms consistent with Tietze syndrome. Although surgical management is not the typical treatment course, symptomatic control was eventually achieved with complete resection of the involved cartilage and adjacent rib. We propose surgical management in patients with debilitating cases of Tietze syndrome that are resistant to conservative therapies.

[Soft tissue swelling of the sternoclavicular joint]. / Weichteilschwellung des Sternoklavikulargelenks.

A 73-year-old woman presented with a swelling of the right sternoclavicular joint the size of a hens egg which had persisted for 2 years. After a corticosteroid injection 8 months previously the swelling was asymptomatic. The magnetic resonance imaging (MRI) scan showed synovialitis of the sternoclavicular joint with edema of the adjacent bone. The constellation is indicative of Tietze syndrome, an inflammation of costochondral junctions of the ribs or chondrosternal joints. The treatment is usually directed at pain relief and benign conditions are often self-limiting.

Non-Hodgkin's lymphoma at the medial clavicular head mimicking Tietze Syndrome.

We present a case of Non-Hodgkin's lymphoma involving medial clavicular head, which was initially diagnosed as Tietze syndrome. Non-Hodgkin's lymphoma arising from medial clavicular head is extremely rare, and CT, MRI findings have not been reported.

Primary chest wall abscess caused by Escherichia coli costochondritis.

Chest wall abscess may occur as primary infection or secondary to open trauma or thoracic wall surgery. The authors describe an unusual case of Escherichia coli costochondritis occurring 2 months after a blunt chest wall trauma. Primary chest wall abscess due to E coli costochondritis has been previously reported only twice occurring after urinary tract infection. All other very few reports of E coli costochondritis have been reported only after thoracic surgical procedures. An English literature review of primary chest wall abscess showed that 4 pathogens are responsible for the majority of cases: Actinomyces, Staphylococcus aureus, Candida albicans and Salmonella. C albicans costochondritis was most commonly reported among heroin addicts. The appearance of a growing chest wall mass should always prompt a search for an infectious cause, even with little or no systemic signs and symptoms.

[Primary suppurative costochondritis--one of our successfully treated cases]. / Primer suppurativ costochondritisrol--egy sikeresen kezelt esetünk kapcsán.

Secondary chest wall infections after previous surgical procedures are well known but the primary form of this is a relatively rare entity. We present a case of a 34-year-old man who suffered from primary suppurative costochondritis diagnosed by ultrasound and chest CT scan. The patient underwent a wide necrosectomy with a muscle flap reconstruction.

Magnetic resonance imaging in Tietze's syndrome.

OBJECTIVE: To evaluate the usefulness of magnetic resonance imaging (MRI) in Tietze's syndrome which, to our knowledge, has not previously been reported in the literature. METHODS: Twelve consecutive outpatients with clinical features of Tietze's syndrome underwent evaluation, including the anamnesis, 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' group were 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 syndrome was characterized as follows: enlargement and thickening of cartilage at 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, due to its high sensitivity, diagnostic reliability and biological advantages thanks to the lack of ionizing radiation.

[Tietze's syndrome in a 2-year old boy]. / Het syndroom van tietze bij een 2-jarige jongen.

A 2-year-old boy was seen with a painful swelling of the left costochondral junction. Laboratory examination revealed no signs of infection. Echography and CT-scan revealed swelling of the 4th and 5th costochondral junction and the pectoral muscle. Tietze's syndrome was suspected and a wait-and-see policy was decided on. During follow-up, the symptoms gradually decreased. Ten weeks after the onset of symptoms there was only a slight, painless swelling with normal ultrasound findings. Tietze's syndrome is defined as a benign, painful, non-suppurative and localised swelling of the costosternal, costochondral or sternoclavicular joints with spontaneous regression of symptoms. It is typically described in adults but appears in children and infants as well. Recognition of this syndrome and knowledge of its favourable outcome can prevent invasive diagnostic procedures.

Ultrasonographic assessment of local steroid injection in Tietze's syndrome.

The purpose of this study was to investigate the value of ultrasonographic examination in the diagnosis of Tietze's syndrome and assessment of the changes in costal cartilage following local steroid injection. Nine patients with Tietze's syndrome and 20 normal subjects were studied consecutively. Ultrasound examination was performed using a Sonoline SL Siemens Machine with a linear 5 MHz small parts transducer and ATL Apogee 800 with a 10 MHz linear array transducer. The affected costochondral joint was injected with a combination of 15 mg of triamcinolone hexacetonide and 1 ml of 2% lidocaine. Ultrasound examination was performed following the clinical evaluation and repeated immediately after the injection, then 1 and 4 weeks later. Abnormal echo appearance was detected as an inhomogeneous increase in the echogenicity with intense broad posterior acoustic shadow. Hypoechogenicity and a decrease in the size of costal cartilage were observed 1 week after local steroid injection with absence of the posterior acoustic shadowing. Ultrasonographic examination of costal cartilage is easy and quick to perform. We believe that ultrasound should be the screening procedure of choice for Tietze's syndrome. Local steroid injection proved to be clinically safe and effective in the treatment of patients with Tietze's syndrome.

[Reflexions on the Tietze syndrome. Clinical contribution]. / Considerazioni sulla sindrome di Tietze. Contributo clinico.

The authors report 4 cases of Tietze's syndrome. In 3 of them the syndrome onset during a rheumatic disease (psoriatic arthritis, sternoclavicular hyperostosis). It is thus necessary to distinguish between the idiopathic of unknown ethiology and the secondary form due to, a well defined disease, in 3 cases observed.

Pinhole skeletal scintigraphic manifestations of Tietze's disease.

Tietze's disease (TD) is a self-limited, non-specific, inflammatory condition of the upper costochondral junction (CCJ). Unlike in many other skeletal diseases, radiography plays a relatively minor role in TD because radiographic changes are frequently obscured by physiological costochondral calcifications. Bone scanning is a sensitive test for TD, but its specificity is low. The present study has been conducted to assess prospectively whether pinhole scintigraphy (PS) can enhance diagnostic specificity in TD. Both planar and PS bone images were obtained in seven ribs of five patients with TD. Scans alterations were analyzed and compared with the radiographic findings. Planar scans showed "hot" areas in the region of the CCJ in all seven ribs, these hot areas lacking textural patterns. However, the magnified PS images of the CCJ showed two characteristic uptake patterns: drumstick-like uptake in acute cases and C- or inverted C-shaped uptake in chronic cases. Radiographically, chondritic sclerosis could be seen when physiological chondral calcifications were minimal or absent, but was observed when the calcification was prominent. The correlation of PS and radiographic findings revealed that C- or inverted C-shaped uptake indeed faithfully reflected the inflammatory process in the CCJ, the medial border of which is concave. The further correlation of magnetic resonance and PS images of two lesions in one patient in whom histological examination was performed showed that C- or inverted C-shaped uptake is closely associated with hypervascularity of TD. Differential diagnosis between TD, fracture and metastasis is discussed.

Costochondritis presenting as a peculiar skin lesion.

Costochondritis is an important complication of median sternotomy that can present months to years after surgery. Delay in diagnosis may result in more disability and increased medical costs. The varied clinical manifestations of costochondritis are reviewed and a case is presented.

Echographic study of Tietze's syndrome.

An echographic study of Tietze's syndrome was carried out. Three patients with clinical evidence of Tietze's syndrome were examined. Ten normal volunteers were studied as controls. In Tietze's syndrome a dishomogeneous increase of the echogenicity in pathological cartilage and an increased thickness vs. the opposite normal side were observed. A moderate thickness and a decreased echogenicity of surrounding soft tissues was observed in one case.

Reliability of computed tomography in the initial diagnosis and follow-up evaluation of Tietze's syndrome: case report with review of the literature.

The clinical entity of Tietze's syndrome is well known. It is benign in nature, self-limiting, and of unknown etiology. Computed tomography has proved most helpful in the initial evaluation of this disorder, especially as roentgenographic plain films have been essentially noncontributory in the past. A case of this disorder was followed up over the course of 2 months, and the clinical and computed tomography findings were correlated. The authors believe that computed tomography is the most exact and reliable modality for the follow-up evaluation of patients with Tietze's syndrome.

Computed tomography of Tietze syndrome.

Six patients with clinical features suggestive of Tietze syndrome had a thoracic computed tomographic (CT) examination following a normal plain film or tomographic examination (or both) of the affected costochondral junction. A chest wall mass was excluded in all six patients. The CT findings included enlargement of the costal cartilage at the site of complaint (two patients), ventral angulation of the involved costal cartilage (two patients), and normal anatomy of the costochondral junction (two patients). Exclusion of a chest wall mass by CT may obviate the need for operative intervention.