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Weekly Chest CasesArchive of Old Cases

Case No : 890 Date 2014-11-17

  • Courtesy of Inyoung Song, Jeong Geun Yi, and Jeong Hee Park / Konkuk University Medical Center, Konkuk University School of Medicine
  • Age/Sex 56 / F
  • Chief ComplaintPain on the right chest wall
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Sternocostoclavicular Hyperostosis, unilateral
Radiologic Findings
Chest PA (Fig1) shows bony sclerosis and overgrowth in right 1st rib and sternal manubrium. Bone window setting of the chest CT scans (Fig 2-3) show mixed sclerotic and osteolytic change and swelling of the sternum, right ribs. Bone scan with technetium 99m methylene diphosphonate (Tc99m-MDP) (Figs 4) shows increased uptake in the sternum, right clavicle and ribs.
Brief Review
Sternocostoclavicular hyperostosis (SCCH) is a chronic inflammatory disorder which presents with erythema, swelling, and pain of the sternoclavicular joint. Approximately one half of patients have acne or pustular lesions with the best described association being with palmoplantar pustulosis (PPP). Extrasternal articular disease occurs in about a quarter of patients. The inflammatory process spans several years and has periods of exacerbation followed by remission. The histologic picture demonstrates a sterile osteomyelitis of the sternum and medial end of the clavicle.
The major radiographic abnormalities of sternocostoclavicular hyperostosis are seen in the anterior and upper portion of the chest wall. Hyperostosis of the sternum, clavicle, and upper ribs is encountered. Additional changes occur in the vertebral column and include spinal outgrowths that resemble those of ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, or psoriatic spondylitis. The focal uptake of radiopharmaceutical on bone scintigraphy called the ‘bullhead’ sign is highly sensitive of SCCH.
Treatment is aimed at easing pain and modifying the inflammatory process. Evidence over the last two decades suggests a role for intravenous bisphosphonates and tumor necrosis factor alpha inhibitors. Untreated chronic inflammation of the sternoclavicular joint leads to restricted mobility and secondary degenerative joint changes. Greater awareness of SCCH is needed to prevent the irreversible physical and psychological impairments associated with the disease.
References
1. Resnick D. Osteomyelitis, septic arthritis, and soft tissue infection: Mechanisms and situations.
2. Carroll MB. Sternocostoclavicular hyperostosis: a review Ther Adv Musculoskelet Dis. 2011 Apr;3(2):101-10
Keywords
Sternum, Non-infectious inflammation,

No. of Applicants : 88

▶ Correct Answer : 62/88,  70.5%
  • - The University of Tokyo Hospital , Japan Akifumi Hagiwara
  • - Kyoto University , Japan Akihiko Sakata
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - Tong young Red cross hospital , Korea (South)
  • - Otsu Red Cross Hospital , Japan Hirotsugu Nakai
  • - Shiga University of Medical Science , Japan Akitoshi Inoue
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - GRMC , India SHAILESH GUPTA
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - University of British Columbia , Canada Amr Ajlan
  • - university of montreal , Canada Andrei Gorgos I
  • - Kyung Hee University Hospital at Gangdong , Korea (South) Seong Jong Yun
  • - GHICL , France manuel toledano
  • - Samsung medical center , Korea (South) Hyun Su Kim
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Ibaraki-gazou-shindan , Japan Shoichi Katoh
  • - 異⑸ , Korea (South) Yunhee Jang
  • - SNUH , Korea (South) Eui Jin Hwang
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Saint Malo , France jean-baptiste Noel
  • - National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
  • - NIMS, HYDERABAD , India ashish sarode
  • - The University of Tokyo Hospital , Japan Toshihiro Furuta
  • - Northern Yokohama Showa university , Japan Kota Watanabe
  • - HIA Legouest - METZ , France Alban Gervaise
  • - The University of Tokyo Hospital , Japan Takeyuki Watadani
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Northern Yokohama Showa university , Japan Noriko Niiya
  • - Asan medical center , Korea (South) Sang Young Oh
  • - National Hospital Organization Okinawa Hospital , Japan Yasuji Oshiro
  • - Kanto Rosai Hospital , Japan tomoko sako
  • - �stanbul , Turkey Ayhan Yilmaz
  • - Haeundae Paik Hospital , Korea (South) In Chul Nam
  • - Asan Medical Center , Korea (South) Jooae Choe
  • - CNUH , Korea (South) Noh Hoon
  • - UZA , Belgium Eline De Smet
  • - CHP St Martin , France mathieu namur
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Ishikawa Matto Central Hospital , Japan Manabu Akimoto
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Chungbuk national university , Korea (South) Yong Kim
  • - VHS medical center , Korea (South) Seong hee Jeon
  • - CNUH , Korea (South) Kim Soo Hyun
  • - IRSA La Rochelle , France Denis Chabassiere
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - CHU Poitiers , France Yannick DE LA TORRE
  • - Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
  • - CHU POITIERS , France SZTARK Guillaume
  • - NASA SCANS , India RAKESH BHATIA
  • - CLCC Rennes , France nicolas gautier
  • - Fortis hospital , Mohali , India Shaleen Rana
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Kobe City Medical Center General Hospital , Japan Yasuhisa Kurata
  • - Gifu Central Hospital , Japan Haruo Watanabe
  • - Chia Nan University of Pharmacy and Science ,Taiwan, R.O.C. , Taiwan Jun Jun Yeh
  • - CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
  • - Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
  • - Freelance resident in Reunion Island , Reunion Fabien HO
  • - Chonnam National University Hospital , Korea (South) So yeon Ki
  • - , Korea (South) Chan Park
  • - Chonnam Nationl University Radiology , Korea (South) juwon kim
  • - Wuhan Union Hospital , China Qiguang Cheng
▶ Correct Answer as Differential Diagnosis : 2/88,  2.3%
  • - MBAL BURGAS , Bulgaria VLADISLAV RUSINOV
  • - Teikyo University Mizonokuchi Hospital , Japan Noriko Kobayashi
▶ Semi-Correct Answer : 3/88,  3.4%
  • - Royal Perth Hospital , Australia Yuranga Weerakkody
  • - NIMS , India Ramesh Allada
  • - CHU Poitiers , France CHAN paul
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