Calcitonin treatment for intersternocostoclavicular ossification: clinical experience in two cases

Sternocostoclavicular hyperostosis: a 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 diagnosis of SCCH is confirmed radiographically by hyperostosis and sclerosis of the sternum with involvement of the first rib on computed tomography (CT). 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. A low level of awareness of SCCH often leads to a delay in diagnosis. This translates into significant morbidity and brings a psychological burden. Untreated chronic inflammation of the sternoclavicular joint leads to restricted mobility and secondary degenerative joint changes. In the search for a diagnosis, patients often undergo multiple serologic and imaging studies and in the experience of the author are referred to multiple specialists before a correct diagnosis is made. Greater awareness of SCCH is needed to prevent the irreversible physical and psychological impairments associated with the disease.

The kaleidoscopic presentation of the spondyloarthritis concept in a female patient

Spondyloarthritis is a group of chronic joint diseases that share clinical, pathological and genetic features and is divided into distinct diagnostic entities, including ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease-associated spondyloarthritis, reactive arthritis, juvenile onset and undifferentiated spondyloarthritis. Since the spectrum of spondyloarthritides is wider than the sum of aforementioned disorders suggests, the term "Spondyloarthritis concept" might prove to be appropriate. Here, we present a case in which many features of the spondyloarthritis concept, but also unexpected osteitis in the skull and tibia, emerge during the disease course. A 45-year-old HLA-B27 positive woman with a family history of psoriasis, a former diagnosis of ankylosing spondylitis, reactive arthritis and fulminating acne, was referred to our department with a painful tibial swelling, symmetrical polyarthritis and severe headache. Conventional radiography and bone scintigraphy demonstrated large osteolytic lesions on the left parietal side of the skull and the right anterior tibia. She was treated with surgery and pamidronate. Etanercept treatment was initiated as the arthritis deteriorated and was replaced by infliximab when new onset Crohn's disease became apparent. This case is the illustration of spondyloarthritis as a disease concept, covering the entire spectrum, from ankylosing spondylitis, urogenital reactive arthritis and psoriatic arthritis to inflammatory bowel disease. Cases like this illustrate that the clinical classification of spondyloarthritis patients into distinct diagnostic entities is bypassing the value of the "concept" and provides support for the new classification criteria that were recently proposed.

Pharmacological management of SAPHO syndrome

The SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome (SaS) includes different skeletal manifestations such as recurrent multifocal osteomyelitis, osteitis and arthritis, which are frequently associated with different forms of skin pustulosis (palmoplantar pustulosis, pustular psoriasis and severe acne). This syndrome is strictly related to the spondyloarthopathies (particularly to psoriatic arthritis) and many SaS cases fulfil the classification criteria for the spondyloarthopathies. Because SaS is an uncommon disease, current knowledge regarding its therapy is based on limited experiences gained by treating mainly small groups of patients. As a consequence, its treatment is still empiric. Several drugs (including NSAIDs, corticosteroids, sulfasalazine, methotrexate, ciclosporin, leflunomide, calcitonin and so on) have been administered and obtained conflicting results. The use of antibiotics, due to the isolation of Propionibacterium acnes from the bone biopsies of several subjects with SaS, has not represented a turning point in therapy, although some patients are responsive to this treatment. Initial reports concerning the administration of bisphosphonates (pamidronate and zoledronic acid) and of an anti-TNF-alpha agent (infliximab) are very promising for the future. In any case, larger, multi-centre, controlled, double-blind studies are required to emerge from the present pioneering phase.

Chronic recurrent multifocal osteomyelitis: five-year outcomes in 14 pediatric cases

OBJECTIVE

To determine the clinical presentation and outcomes of chronic recurrent multifocal osteomyelitis (CRMO) in pediatric patients.

PATIENTS AND METHODS

Ten girls and four boys were followed up between 1993 and 1999 for CRMO diagnosed on the basis of radiographic bone lesions with, at the same sites, increased radionuclide uptake, negative microbiological specimens, and histological evidence of nonspecific osteomyelitis.

RESULTS

Mean age at CRMO was 9.6+/-3.4 years, mean disease duration was 5.3+/-2.5 years, and mean number of flares per patient was 5.9+/-3.7. Thirty-four percent of lesions were in the metaphyses of the lower limb bones, 14% in the pelvis, and 13% in the chest wall (with clavicular lesions in four patients). Three patients had skin lesions (psoriasis in two and palmoplantar pustulosis in one). Eight patients received antibiotic therapy, for 2 months at the most, to no advantage in the short term. Nonsteroidal anti-inflammatory drugs were used in all 14 patients and glucocorticoid therapy in four. Sulfasalazine was used in five patients, to good effect in four. Mean follow-up was 5.3+/-2.5 years. At last follow-up, eight patients had active disease, including one with synovitis and one with Takayashu's disease.

CONCLUSION

As compared to SAPHO syndrome, skin lesions and chest wall involvement are less common in CRMO. The long-term prognosis is guarded: in our study only six of 14 patients were in remission at last follow-up.

The sternoclavicular syndrome: experience from a district general hospital and results of a national postal survey

OBJECTIVE

To report our local experience of the sternoclavicular syndrome and sample the experience of other rheumatologists in the UK.

METHODS

We studied case records of 23 patients referred to the Southend rheumatology clinic and data obtained from a postal questionnaire survey of British rheumatologists.

RESULTS

We describe 58 cases (20 males and 38 females, mean age 47.2 yr). The disease was unilateral in 40 patients. Shoulder and/or arm pain (38 cases) with limitation of shoulder movements was an important presenting feature; other presenting features were anterior chest wall pain (14 cases) and neck pain (15 cases). Peripheral joint involvement was seen in 12 cases. Skin rash was reported in 12 cases (psoriasis, 6; acne, 2; none had pustulosis). No patients had symptoms or signs of sacroiliitis, and HLA-B27 was negative in 22 out of 23 patients. 99Technetium scintiscanning showed increased uptake in the sternoclavicular region in 31/34 patients (91.1%), but not in the sacroiliac areas. Plain radiographs were abnormal in 18 cases (sclerosis, 9; erosions, 2; soft tissue swelling, 2; bony expansion, 5). CT and/or MRI scans (available in 27 cases) showed erosions in 12 and osteitis in 18. Available histology showed a variable picture, including inflammation, bone erosion, sterile osteomyelitis and fibrosis. The majority of patients (45) were treated with non-steroidal anti-inflammatory drugs: 12 received steroids and 10 received disease-modifying anti-rheumatic drugs (methotrexate, 4; sulphasalazine, 6). Follow-up information was available for 38 patients, of whom 14 became asymptomatic and 24 had chronic disease with intermittent flares.

CONCLUSION

Sternoclavicular disease is not uncommon in the UK. It can present with pain in the shoulder, neck or anterior chest wall, and may be underdiagnosed. Our results do not show a link with acne or pustulosis. Features of spondyloarthropathies, such as sacroiliitis and HLA-B27 positivity, were rare in this survey.

Acquired hyperostosis syndrome--AHYS--(sternocostoclavicular hyperostosis, pustulotic arthro-osteitis, SAPHO-syndrome): bone scintigraphy of the anterior chest wall

The objective of this report is to provide a description of diagnostically significant scintigraphically recognizable sites and patterns of acquired hyperostosis syndrome (AHYS) on the anterior chest wall (ACW), which is involved in 82% of AHYS patients. In 49/90 of our own AHYS patients, planar bone scans of the ACW were performed with the gamma camera, applying an average of 650 MBq of 99mTc-phosphate complexes. In addition, 53 atraumatic patients with extrathoracic cancer were available for routine whole-body scintigraphy. None of these patients had increased uptake identifiable as metastasis clinically or by imaging modalities in either the ACW or the rest of the skeleton. The scintigraphic involvement of the various morphological ACW structures is described in AHYS. Moreover, attention is called to the diagnostic significance of focal hyperactivities at the anterior end of the 2nd-8th rib of adults, which are in the 5th place with respect to their frequency in AHYS. The diagnostic significance of sternocostal-joint involvement in AHYS can likewise be recognized by bone-scan scintigraphy and will be discussed. Bone scintigraphy is more sensitive than radiomorphological imaging in AHYS. This, however, only applies under three conditions. 1. The increased radiotracer uptake in the upper sternocostoclavicular region must be assessed on both the anterior and the posterior view of the ACW scan. 2. In addition to the anterior view of the routine scintiscan, further anterior scans with reduced scan time of the gamma camera are usually necessary. This ensures better visibility of the involvement of certain morphological structures that are important for AHYS diagnosis. Moreover, a statement can be made about the inflammatory ossifying activity/inactivity of the AHYS on ACW.3. Increased radionuclide uptake in the manubrium sterni and corpus sterni on the anterior scan should be verified by additional lateral or oblique scans of the thorax (sternum).

Computed tomography in sternocostoclavicular hyperostosis

Sternocostoclavicular hyperostosis is a rare but recognized entity characterized by new bone formation and ligamentous ossification which limits mobility of the sternoclavicular joints. Aetiology is obscure and debated. There may be considerable delay in establishing the diagnosis, even by specialists. In confirming the diagnosis plain radiography is of limited value but radionuclide bone scan and computed tomography (CT) may be helpful. Four cases are described to emphasize these points and illustrate the clinical and radiological features of the condition. High resolution CT with thin sections (5 mm or less) is the examination of choice for demonstrating the characteristic features and is essential if the condition is to be confirmed in its early stages when treatment might be more successful in delaying progression.