magnetic resonance imaging in tietzeâ€™s syndrome

Magnetic resonance imaging in Tietze’s syndromeL. 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.

AbstractObjective

To evaluate the usefulness of magnetic resonance imaging (MRI) in Tietze’s syndrome which, to our knowledge, has not ’s syndrome which, to our knowledge, has not ’previously been reported in the literature.

MethodsTwelve consecutive outpatients with clinical features of Tietze’s syndrome underwent evaluation, including the anamnesis, ’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’ 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).

ResultsThe MRI pattern of primary Tietze’s syndrome was characterized as follows: enlargement and thickening of cartilage at ’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).

ConclusionMagnetic 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 ’s syndrome, due to its high sensitivity, diagnostic reliability and ’

biological advantages thanks to the lack of ionizing radiation.

Key wordsTietze’s syndrome, magnetic resonance imaging, diagnosis, costosternal joints, sternoclavicular joints.

Clinical and Experimental Rheumatology 2008; 26: 848-853.

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MRI in Tietze’s sindrome / L. Volterrani et al.

Luca Volterrani, MD, Prof. of Radiology Maria Antonietta Mazzei, MDNicola Giordano, MD, Prof. of RheumatologyRanuccio Nuti, MD, Prof. of Int. Medicine Mauro Galeazzi, MD, Prof. of RheumatologyAntonella Fioravanti, MDPlease 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] on July 26, 2007; accepted in revised form on March 19, 2008.© Copyright © Copyright © CLINICAL AND EXPERIMENTAL RHEUMATOLOGY 2008.EXPERIMENTAL RHEUMATOLOGY 2008.EXPERIMENTAL RHEUMATOLOGY

Competing interests: none declared.

IntroductionNamed in 1921 after Alexander Tietze, a German surgeon (1), Tietze’s syn-drome, also known as costochondritis, is an infl ammatory process involv-ing one or more of the costochondral cartilages. Tietze’s syndrome can be defi ned as a benign, painful, non-sup-purative, 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 dis-order (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 simul-taneously (2, 3). The exact occurrence of this condition is not well known. It predominantly strikes subjects between twenty and fi fty years of age, even if cases in children and the elderly have been documented (3, 4). Moreover, it has been reported that females are di-agnosed with the disease more often than males by a 2:1 ratio (2). The ae-tiopathogenesis of Tietze’s syndrome is still being debated: the micro-trau-matic theory currently seems to be the most cited one (3, 5, 6). Histological examinations of the swellings showed non-specifi c fi ndings in the hyaline cartilage, consisting of an increased vascularity and degenerative changes with patchy loss of ground substance leading to a fi brillar 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 radiologi-cal techniques have been suggested to confi rm the diagnosis, but there are few studies on the value of conventional ra-diography (16, 17), computed tomog-raphy (CT) (18, 19), scintigraphy with 67Ga and 99mTc diphosphonate (20, 21), and ultrasound (US) (22-25). Mag-netic resonance (MR) (26) is an excel-lent 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 ar-thritis and malignant tumours (26, 29), which may mimic Tietze’s syndrome. The purpose of the present study was

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 methodsBetween 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 Medi-cine (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 his-tory, 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 up-per respiratory tract infection, or either signs and/or symptoms of systemic dis-ease. Furthermore, a series of labora-tory exams including blood cell count, erythrocyte sedimentation rate, C-re-active protein, serum uric acid, lactate dehydrogenase, creatine phosphoki-nase (CPK), CPK-MB, troponin, rheu-matoid factor, anti-cyclic citrullinated peptide antibodies and urinalysis were performed. Bacterial, viral, and my-cotic 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 sub-jects, age and sex matched, were exam-ined in a similar manner. The study was approved by the Ethics Committee of the School of Medicine of the Univer-sity of Siena. All patients provided in-formed oral consent. In all the individ-uals 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 superfi cial and phased array detection receiving coil. Subjects were placed prone on the MRI table to reduce respiratory mo-tion artefacts, arms alongside the body.

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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-en-hanced sequences with fat saturation

were taken for all patients examined on the Gyroscan MR unit. The princi-pal 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 imag-ing fi ndings were evaluated: abnormal thickness and abnormal signal inten-sity (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 ab-sence of cortical bone erosion, abnormal signal intensity of subcondral bone (de-creased signal intensity on T1-weighted images, increased signal intensity on

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 oppo-site normal side (18). The enhancement characteristics of the abnormal tissue after gadolinium-based contrast mate-rial injections were also evaluated. The fi nal decision regarding MR morphol-ogy as well as MR signal characteristics and enhancement of the cartilaginous, bone and joint components was done by consensus.

ResultsBiochemical parameters, chest x-rays and electrocardiogram appeared within the normal limits for both patients and control subjects; cultures also gave neg-ative results in patients and controls.

Normal subjectsAmong the 20 normal subjects exam-ined, 14 presented signs that are known to be “degenerative”: osteophytes, me-niscal calcifi cation, calcifi cation of the costal cartilage and bone sclerosis. In order to help the reader to differentiate between normal and pathological pat-terns, MRI fi ndings 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 fi rst rib. It is completely divided into two articular compartments by a fi brocartilaginous disk. SCJ and cos-tosternal 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 in-termediate signal intensity on FSE T1-weighted images and hypo-intense on FSE T2-weighted, STIR and FAT SAT images without enhancement in post-contrast images.The enhancement pattern of the peri-articular and intra-articular structures and surrounding bone after administra-tion of gadolinium was gradual, pro-gressive and homogeneous.

Table II. Technical parameters of principal utilized MR sequences.

Sequences TR (ms) TE (ms) TI (ms) Matrix Section Acquisition MR unit (pixel) thickness/ time (min) gap (mm)

FSE* T1 756 9 256X512 3.00/0.3 5:54 Gyroscan weighted NT 1.5 TFSE T2 3500-4000 100-120 196X256 3.00/0.3 3:33 Gyroscan weighted NT 1.5 TSTIR** 1400 20 155 176X256 3.00/0.3 6:45 Gyroscan NT 1.5 TFSE T1 600 10.3 384X256 4.00/0.4 5:15 GE Signa 1.5 TT2 FAT 3560 101 384X256 4.00/0.4 2:58 GE Signa SAT*** 1.5 TFSPGR**** 100 2-8 320X288 3.00/0.3 0.58 GE Signa 1.5 T

*FSE: fast spin echo; **STIR: short time inversion recovery; ***SAT: saturation; ****FSPGR: fast spoiled gradient echo.

Table I. Demographic data and clinical features of patients with Tietze’s syndrome.

Patient Age (year)/sex Duration of Clinical fi ndings Tietze’s syndrome, when fi rst examined (years)

1 70/F 2 Painful tender swelling of the right SCJ2 62/F 0.6 Painful swelling of the right SCJ3 56/F 1.6 Painful swelling of either SCJ4 62/F 3 Painful swelling at left fi rst costochondral junction5 64/F 1.5 Painful swelling of either SCJ6 56/F 2.3 Painful swelling of the right SCJ7 58/F 0.6 Painful swelling of the right SCJ8 42/M 0.8 Painful of the left third costochondral junction9 58/F 0.8 Painful of the left SCJ10 29/F 1 Painful swelling at right third costochondral junc- tion11 56/F 0.6 Painful tender swelling of the right SCJ12 60/M 1.8 Painful swelling of the right second costochondral junction

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Patients with Tietze’s syndrome ’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 exam-ined, no mass was identifi ed at the site of complaint. The results obtained with MR are reported in Table III. In par-ticular, enlargement and thickening of the hyaline cartilage at the site of com-plaint was found in 12/12 patients, fo-cal 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 carti-lage with focal or widespread increased signal intensity. Bone marrow oedema was often noticeable in the subcondral bone of the involved cartilage; in ad-dition, 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.

DiscussionIn 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 fi ndings confi rm 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 prevalent-ly monolateral (10/12) and more often affected the right ribs (2/12) or the right SCJ (7/12), probably due to its micro-traumatic aetiology (3). Analysing the literature on Tietze’s syndrome, we not-ed 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 dis-eases, in particular in spondyloarthri-tis, psoriatic arthritis, sternoclavicular hyperostosis, and SAPHO syndrome (8, 10, 14, 28, 30). Tietze’s syndrome is included in the dif-ferential diagnosis of visceral anterior

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 T2- weighted 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 fi rst condrosternal junction.A. axial T1-weighted MR image shows enlargement of the left fi rst cartilage (black arrow). B and C,coronal FSE T2 and STIR images, respectively, show oedema in the subcondral bone of the sternum (black arrows).

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chest wall pain (31, 32). Many diagnos-tic techniques have been used to inves-tigate 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. Scinti-graphy (19, 20) shows an abnormal ac-cumulation of 67Gallium and 99mTc di-phosphonate at the level of the involved joint, but this technique is un-specifi c and is unable to represent different com-ponents of the examined joint. US (22-25) shows an inhomogeneous increase

in echogenicity and thickness of patho-logical cartilage compared to the oppo-site normal side. Furthermore, it shows in real time the topographic correspond-ence between the cartilage alterations and the painful swelling, increased by digital pressure. This technique, howev-er, 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 lin-ear scanner usually utilized is not wide enough to scan simultaneously the two sides so that the comparison is only pos-sible by fl anking 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-men-tioned 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 clini-cal features of Tietze’s syndrome: the spectrum of CT fi ndings includes focal cartilage enlargement, ventral angula-tions of the costal cartilage and normal anatomic features. The author (18) con-cluded affi rming that CT is able to show the costal cartilage, bone and adjacent structures and to defi ne the characteris-tics of the mass noted during the clini-cal 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 hya-line 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 ad-ministration of gadolinium, respectively, show enlarged right SCJ cartilage and contrast enhancement of affected cartilage and capsular components (black thin arrows).

Table III. Pathological MR fi ndings.

Patient 1 2 3 4 5 6 7 8 9 10 11 12Site of complaint right right either left fi rst either right right left third left right third right right second SCJ SCJ SCJ costochondral SCJ SCJ SCJ costochondral SCJ costochondral SCJ costochon- junction junction junction dral junction

Enlargement and thickening Y Y Y Y Y Y Y Y Y Y Y Y of hyaline cartilage (particular left side) Focal or widespread oedema – Y – Y Y Y Y Y Y Y Y Y of cartilage Bone marrow oedema in the Y Y Y Y – Y – – – – – – subcondral bone (left) Gadolinium uptake of cartilage Y Y Y low Y Y Y Y Y – Y YGadolinium uptake of Y Y Y Y – low – – – – – – subcondral bone Gadolinium uptake of capsular Y Y Y low Y Y Y – Y – – – components

Y= yes.

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has not been amply investigated. In the present study, we have reported the spectrum of MR fi ndings in twelve patients with clinical characteristics of Tietze’s syndrome; to our knowledge similar studies are not present in litera-ture until now. MR images revealed a characteristic spectrum of abnormali-ties in patients with Tietze’s syndrome compared with MR images taken in normal subjects. In detail, the specifi c MR fi ndings 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 fi ndings confi rmed the histological observations of hyper-vascularization 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 syn-drome, histologically examined, and documented a blood vessel in a central area of cartilage degeneration. Further-more they described columns of carti-lage, indicating proliferative activity, at the periphery of the shaving. Prob-ably 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 carti-lage 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 advan-tages of using MR compared to other techniques, are the capacity to detect damage of the cartilaginous compo-nents 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 confi rm the clinical diagnosis and to exclude other painful wall chest

pathologies. In conclusion, we recom-mend MR as the elective method in the investigation of Tietze’s syndrome, due to its high sensitivity, diagnostic relia-bility and biological advantages thanks to the lack of ionizing radiation.

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magnetic resonance imaging in tietzeâ€™s syndrome

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