Magnetic resonance imaging in Tietze`s syndrome

Magnetic resonance imaging in Tietze’s syndrome
L. Volterrani1, M.A. Mazzei2, N. Giordano3, R. Nuti3, M. Galeazzi4, A. Fioravanti4
Department of Human Pathology and Oncology, 3Department of Internal Medicine, and
4
Rheumatology 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.
1
Abstract
Objective
To evaluate the usefulness of magnetic resonance imaging (MRI) in Tietze’s
’’s syndrome which, to our knowledge, has not
previously been reported in the literature.
Methods
Twelve consecutive outpatients with clinical features of Tietze’s
’’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
’’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
’’s syndrome, due to its high sensitivity, diagnostic reliability and
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
Maria Antonietta Mazzei, MD
Nicola Giordano, MD, Prof. of Rheumatology
Ranuccio Nuti, MD, Prof. of Int. Medicine
Mauro Galeazzi, MD, Prof. of Rheumatology
Antonella Fioravanti, MD
Please address correspondence and
reprint requests to:
Dr. Maria Antonietta Mazzei,
Radiologia Universitaria,
Policlinico Santa Maria alle Scotte,
Azienda Ospedaliera Universitaria Senese,
Viale Bracci 2, Siena 53100, Italy.
E-mail: [email protected]
[email protected]
Received on July 26, 2007; accepted in
revised form on March 19, 2008.
© Copyright CLINICAL AND
EXPERIMENTAL RHEUMATOLOGY 2008.
Competing interests: none declared.
Introduction
Named in 1921 after Alexander Tietze,
a German surgeon (1), Tietze’s syndrome, also known as costochondritis,
is an inflammatory process involving one or more of the costochondral
cartilages. Tietze’s syndrome can be
defined as a benign, painful, non-suppurative, with localised swelling of
the costosternal, costochondral, and/or
sternoclavicular joints (SCJ) (Tietze’s
area), in the absence of other causes
which could be responsible for this disorder (1, 2). In most cases (80%), only
one costal cartilage is involved (most
commonly the second or the third rib),
but other joints can be affected simultaneously (2, 3). The exact occurrence
of this condition is not well known. It
predominantly strikes subjects between
twenty and fifty years of age, even if
cases in children and the elderly have
been documented (3, 4). Moreover, it
has been reported that females are diagnosed with the disease more often
than males by a 2:1 ratio (2). The aetiopathogenesis of Tietze’s syndrome
is still being debated: the micro-traumatic theory currently seems to be the
most cited one (3, 5, 6). Histological
examinations of the swellings showed
non-specific findings in the hyaline
cartilage, consisting of an increased
vascularity and degenerative changes
with patchy loss of ground substance
leading to a fibrillar appearance (7).
Different rheumatic and non-rheumatic
diseases can account for pain with or
without swelling around Tietze’s area
(8-15). The diagnosis of this condition
is primarily clinical. Many radiological techniques have been suggested to
confirm the diagnosis, but there are few
studies on the value of conventional radiography (16, 17), computed tomography (CT) (18, 19), scintigraphy with
67Ga and 99mTc diphosphonate (20,
21), and ultrasound (US) (22-25). Magnetic resonance (MR) (26) is an excellent technique to show cartilaginous,
joints and bone abnormalities: it has
been employed in cases of chest wall
pain following thoracic trauma (27),
spondyloarthropathies (28), septic arthritis and malignant tumours (26, 29),
which may mimic Tietze’s syndrome.
The purpose of the present study was
849
to evaluate the usefulness of MR in the
diagnosis of Tietze’s syndrome which,
to our knowledge, has not previously
been reported in the literature.
Patients and methods
Between July 2004 and December
2006, 12 consecutive outpatients (ten
women and two men, mean age 56.08
years, age range 29 to 70 years) with
Tietze’s syndrome were observed at the
Rheumatology Unit (A. F. and M. G.)
and the Department of Internal Medicine (N.G. and R.N.) of the University
of Siena. The demographic data and
clinical characteristics of the patients
are summarized in Table I. The same
rheumatologist performed patients’
evaluation, including the medical history, general examination and clinical
evaluation of costosternal joints and
SCJ. All the subjects examined had no
history of thoracic trauma, aggressive
exercise able to cause strain, prior upper respiratory tract infection, or either
signs and/or symptoms of systemic disease. Furthermore, a series of laboratory exams including blood cell count,
erythrocyte sedimentation rate, C-reactive protein, serum uric acid, lactate
dehydrogenase, creatine phosphokinase (CPK), CPK-MB, troponin, rheumatoid factor, anti-cyclic citrullinated
peptide antibodies and urinalysis were
performed. Bacterial, viral, and mycotic cultures of blood, sputum, urine
and stools were also collected, in order
to exclude other pathologies. Finally,
chest x-rays and electrocardiograms
(ECG) were recorded for all patients.
During the same period, 20 normal subjects, age and sex matched, were examined in a similar manner. The study was
approved by the Ethics Committee of
the School of Medicine of the University of Siena. All patients provided informed oral consent. In all the individuals examined, an MR imaging of the
anterior thoracic wall was performed
by using a 1.5 Tesla unit (Gyroscan
NT 1.5 Philips, The Netherlands and
GE Signa Excite HD, GE Healthcare,
Milwaukee, Wis.) with a superficial
and phased array detection receiving
coil. Subjects were placed prone on the
MRI table to reduce respiratory motion artefacts, arms alongside the body.
MRI in Tietze’s sindrome / L. Volterrani et al.
Table I. Demographic data and clinical features of patients with Tietze’s syndrome.
Patient
Age (year)/sex
Duration of
Tietze’s syndrome,
when first examined
(years)
1
2
3
4
5
6
7
8
9
10
70/F
62/F
56/F
62/F
64/F
56/F
58/F
42/M
58/F
29/F
2
0.6
1.6
3
1.5
2.3
0.6
0.8
0.8
1
11
12
56/F
60/M
0.6
1.8
In the pre-contrast examination, fast
spin-echo T1-weighted (FSE T1) on
axial or coronal planes, fast spin-echo
T2-weighted (FSE T2) and T2 STIR
(short time inversion recovery) or FAT
SAT (saturation) sequences on coronal
planes were chosen. For all sequences,
slice thickness was 3-4 mm and slices
were separated by 0.3-0.4 mm gaps.
In all patients 0,2 ml gadolinium/kg
body weight (Magnevist, Schering,
Berlin, Germany) was administered
and dynamic acquisition with gradient
echo sequences on coronal planes were
conducted with the same TR and TE
as the pre-contrast scans on GE Signa
MR unit. T1-weighted gadolinium-enhanced sequences with fat saturation
Clinical findings
Painful tender swelling of the right SCJ
Painful swelling of the right SCJ
Painful swelling of either SCJ
Painful swelling at left first costochondral junction
Painful swelling of either SCJ
Painful swelling of the right SCJ
Painful swelling of the right SCJ
Painful of the left third costochondral junction
Painful of the left SCJ
Painful swelling at right third costochondral junction
Painful tender swelling of the right SCJ
Painful swelling of the right second costochondral
junction
were taken for all patients examined
on the Gyroscan MR unit. The principal data of the MR sequences used are
reported in Table II. The MR images
were evaluated by two experienced
musculoskeletal radiologists (L.V. and
M.A.M.). The following MR imaging findings were evaluated: abnormal
thickness and abnormal signal intensity (increased signal intensity on T2
STIR or FAT SAT weighted images)
of the hyaline cartilage compared with
the thickness and signal intensity of the
controlateral cartilage, presence or absence of cortical bone erosion, abnormal
signal intensity of subcondral bone (decreased signal intensity on T1-weighted
images, increased signal intensity on
Table II. Technical parameters of principal utilized MR sequences.
Sequences
TR (ms)
TE (ms)
FSE* T1
weighted
756
9
FSE T2
3500-4000
weighted
TI (ms)
100-120
Section Acquisition
thickness/ time (min)
gap (mm)
256X512
3.00/0.3
5:54
196X256
3.00/0.3
3:33
176X256
3.00/0.3
6:45
STIR**
1400
20
FSE T1
600
10.3
384X256
4.00/0.4
5:15
3560
101
384X256
4.00/0.4
2:58
100
2-8
320X288
3.00/0.3
0.58
T2 FAT
SAT***
FSPGR****
155
Matrix
(pixel)
*FSE:
MR unit
Gyroscan
NT 1.5 T
Gyroscan
NT 1.5 T
Gyroscan
NT 1.5 T
GE Signa
1.5 T
GE Signa
1.5 T
GE Signa
1.5 T
fast spin echo; **STIR: short time inversion recovery; ***SAT: saturation; ****FSPGR: fast
spoiled gradient echo.
850
T2-weighted images) compared with
the normal bone signal intensity, and
capsular and ligament involvement.
The criterion for diagnosis of cartilage
enlargement used was represented by
the thickened and bulbous aspect of the
affected tissue compared to the opposite normal side (18). The enhancement
characteristics of the abnormal tissue
after gadolinium-based contrast material injections were also evaluated. The
final decision regarding MR morphology as well as MR signal characteristics
and enhancement of the cartilaginous,
bone and joint components was done by
consensus.
Results
Biochemical parameters, chest x-rays
and electrocardiogram appeared within
the normal limits for both patients and
control subjects; cultures also gave negative results in patients and controls.
Normal subjects
Among the 20 normal subjects examined, 14 presented signs that are known
to be “degenerative”: osteophytes, meniscal calcification, calcification of the
costal cartilage and bone sclerosis. In
order to help the reader to differentiate
between normal and pathological patterns, MRI findings of normal SCJ and
condrosternal joints in a young patient
are shown in Figure 1 (A-E).
The SCJ is formed by the sternal end
of the clavicle, the clavicular notch of
the manubrium sterni, and the cartilage
of the first rib. It is completely divided
into two articular compartments by a
fibrocartilaginous disk. SCJ and costosternal cartilage size may vary with
body habitus and costal cartilage level,
even if the costal cartilage is normally
symmetrical in size and orientation at
any single level (18, 19). MR imaging
showed the normal cartilage as an intermediate signal intensity on FSE T1weighted images and hypo-intense on
FSE T2-weighted, STIR and FAT SAT
images without enhancement in postcontrast images.
The enhancement pattern of the periarticular and intra-articular structures
and surrounding bone after administration of gadolinium was gradual, progressive and homogeneous.
MRI in Tietze’s sindrome / L. Volterrani et al.
Patients with Tietze’s
’’s syndrome
The peculiar MR pattern in Tietze’s
syndrome is shown in Figures 2 (A-C)
and 3 (A-D). In all the subjects examined, no mass was identified at the site
of complaint. The results obtained with
MR are reported in Table III. In particular, enlargement and thickening of
the hyaline cartilage at the site of complaint was found in 12/12 patients, focal or widespread oedema of cartilage
was found in 10/12 patients, marrow
oedema in the subcondral bone in 5/12
patients, vivid gadolinium uptake of
the cartilage, the subcondral bone and
capsular components in 10/12, 4/12
and 7/12 patients respectively. Both
TSE T2-weighted and STIR or FAT
SAT images showed thickened cartilage with focal or widespread increased
signal intensity. Bone marrow oedema
was often noticeable in the subcondral
bone of the involved cartilage; in addition, in post-contrast MR images,
vivid gadolinium uptake was present in
the areas of thickened cartilage, in the
subcondral bone marrow and/or in the
other peri-articular components.
Fig. 1. 35-year-old woman without involvement of anterior chest wall. Images show normal MR
appearance of the SCJ and condrosternal joints on coronal T1-weighted MR image (A) coronal T2weighted MR image (B). Coronal T2 STIR image (C) and normal MR appearance of the SCJ and of
the condrosternal joints on axial T1- weighted MR image respectively (D and E).
Fig. 2. 62-year-old woman with painful swelling at left first condrosternal junction.
A. axial T1-weighted MR image shows enlargement of the left first cartilage (black arrow). B and C,
coronal FSE T2 and STIR images, respectively, show oedema in the subcondral bone of the sternum
(black arrows).
851
Discussion
In the present study, we examined 12
consecutive outpatients with clinical
characteristics of Tietze’s syndrome, 10
females and 2 males, aged between 29
and 70 years. The findings confirm the
data already found in the literature (2,
3) on the high prevalence of the disease
in adults and in the female gender. As
previously reported (2, 3), also in our
cases Tietze’s syndrome was prevalently monolateral (10/12) and more often
affected the right ribs (2/12) or the right
SCJ (7/12), probably due to its microtraumatic aetiology (3). Analysing the
literature on Tietze’s syndrome, we noted that costosternal, costochondral and
SCJ involvement, often neglected in
the past, has recently been the object of
a great deal of interest, probably due to
recent reports of the anterior chest wall
involvement in many rheumatic diseases, in particular in spondyloarthritis, psoriatic arthritis, sternoclavicular
hyperostosis, and SAPHO syndrome
(8, 10, 14, 28, 30).
Tietze’s syndrome is included in the differential diagnosis of visceral anterior
MRI in Tietze’s sindrome / L. Volterrani et al.
in echogenicity and thickness of pathological cartilage compared to the opposite normal side. Furthermore, it shows
in real time the topographic correspondence between the cartilage alterations
and the painful swelling, increased by
digital pressure. This technique, however, has some limits as it does not allow
an immediate comparison between the
two sides; this is due mainly to technical
reasons. In particular, the 7-12 MHz linear scanner usually utilized is not wide
enough to scan simultaneously the two
sides so that the comparison is only possible by flanking the images obtained
separately. Moreover, this technique
depends strongly on the operator and it
is not suitable for getting a clear image
of the complex anatomy of the SCJ and
condrosternal joints; the above-mentioned joints’ anatomy is well shown
by CT and MR imaging. Edelstein et
al. (18) proved the usefulness of CT in
the evaluation of six patients with clinical features of Tietze’s syndrome: the
spectrum of CT findings includes focal
cartilage enlargement, ventral angulations of the costal cartilage and normal
anatomic features. The author (18) concluded affirming that CT is able to show
the costal cartilage, bone and adjacent
structures and to define the characteristics of the mass noted during the clinical exam. Even if MR is an excellent
technique for highlighting cartilage and
bone abnormalities (26, 28), its value
in the diagnosis of Tietze’s syndrome
Fig. 3. 70-year-old woman with painful tender swelling of the right SCJ.
A and B coronal T2-weighted and T2 FAT SAT MR images show enlarged right SCJ cartilage (white
arrow) with abnormal signal intensity (increased signal intensity on T2-weighted images) of the hyaline cartilage (black arrows) and focal area of oedema in the subcondral bone of the sternal end of the
right clavicle (white thin arrow). C and D axial T1-weighted images before and after intravenous administration of gadolinium, respectively, show enlarged right SCJ cartilage and contrast enhancement
of affected cartilage and capsular components (black thin arrows).
chest wall pain (31, 32). Many diagnostic techniques have been used to investigate Tietze’s syndrome, but only a few
studies have analysed and compared the
suitability of radiography (16, 17), CT
(18, 19), scintigraphy (20, 21), and US
(22-25). In many cases, conventional
radiological methods (standard x-rays,
conventional tomography) (16,17) help
to exclude bone lesions, but they are not
able to show cartilage damage. Scintigraphy (19, 20) shows an abnormal accumulation of 67Gallium and 99mTc diphosphonate at the level of the involved
joint, but this technique is un-specific
and is unable to represent different components of the examined joint. US (2225) shows an inhomogeneous increase
Table III. Pathological MR findings.
Patient
Site of complaint
1
right
SCJ
2
right
SCJ
Enlargement and thickening
of hyaline cartilage
Y
Y
Y
Focal or widespread oedema
of cartilage
–
Y
–
Bone marrow oedema in the
subcondral bone
Y
Y
Y
(left)
Gadolinium uptake of
subcondral bone
Y
Y
Y
Y
Y
Gadolinium uptake of cartilage
Gadolinium uptake of capsular
components
Y
Y
3
4
5
either
left first
either
SCJ costochondral SCJ
junction
Y
(particular
left side)
6
right
SCJ
7
8
9
10
11
12
right
left third
left
right third right right second
SCJ costochondral SCJ costochondral SCJ costochonjunction
junction
dral junction
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
–
Y
–
–
–
–
–
–
Y
low
Y
–
low
Y
Y
Y
Y
–
–
–
Y
Y
Y
low
Y
Y
Y
–
Y
–
–
–
Y
Y= yes.
852
–
–
–
–
MRI in Tietze’s sindrome / L. Volterrani et al.
has not been amply investigated. In
the present study, we have reported
the spectrum of MR findings in twelve
patients with clinical characteristics of
Tietze’s syndrome; to our knowledge
similar studies are not present in literature until now. MR images revealed a
characteristic spectrum of abnormalities in patients with Tietze’s syndrome
compared with MR images taken in
normal subjects. In detail, the specific
MR findings were represented by focal
cartilage enlargement, oedema of the
cartilage and the subcondral bone, vivid
and rapid contrast enhancement of the
cartilage and peri-articular structures
involved. These MR findings confirmed
the histological observations of hypervascularization and degeneration of the
hyaline cartilage, reported by Cameron
and Fornasier (7). Normal cartilage is
not vascularised, however the authors
described one case of Tietze’s syndrome, histologically examined, and
documented a blood vessel in a central
area of cartilage degeneration. Furthermore they described columns of cartilage, indicating proliferative activity,
at the periphery of the shaving. Probably it is possible to assume that the
hypertrophic changes of the cartilage
should be coupled with angiogenesis,
as showed in our investigation by vivid
gadolinium enhancement of the cartilage in post-contrast MR images. This
observation is in accordance to recent
studies that describe the osteochondral
junction angiogenesis in osteoarthritis
(33, 34). Our study demonstrated that
MR images were able to show changes
in cartilage and bone marrow oedema,
which could not be revealed by CT.
We believe that the greatest advantages of using MR compared to other
techniques, are the capacity to detect
damage of the cartilaginous components and sub-condral bone in the
form of oedema and the vivid contrast
enhancement after gadolinium-based
injections. On the basis of the present
study, we want to underline that, even
if the diagnosis of Tietze’s syndrome is
essentially clinical, MR investigation is
useful to confirm the clinical diagnosis
and to exclude other painful wall chest
pathologies. In conclusion, we recommend MR as the elective method in the
investigation of Tietze’s syndrome, due
to its high sensitivity, diagnostic reliability and biological advantages thanks
to the lack of ionizing radiation.
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