MRI in a patient with unilateral parasternal pain: a case of Tietze syndrome

A 28-year-old female presents herself at the radiology department for magnetic resonance imaging (MRI) of the anterior chest wall for evaluation of spontaneous non-traumatic left parasternal pain and mild unilateral swelling for three months.

Hypointense signal on T1-weighted images and hyperintense signal on T2-weighted proton density (PD) and T2-weighted triple inversion recovery (TIR) images is seen at the middle third of the cartilage at the left anterior margin of the second rib with surrounding soft tissue hyperintense signal on T2-weighted TIR sequence. All sequences show hypertrophy of the cartilage of the anterior margin of the second rib on the left compared to the other costochondral junctions. After intravenous gadolinium injection, there is focal to nodular contrast enhancement of the anterior costochondral junction of the second rib on the left.

Background

Tietze’s syndrome is a rare, self-limiting, non-suppurative, benign arthropathy. The pathogenesis of Tietze syndrome remains unknown but it is thought to relate to recurrent microtrauma and/or airway infection. [1] The disease often involves one of the sternochondral junctions, costochondral junctions, or sternoclavicular joints, although multiple joints may be involved. The second or third ribs are most often involved. The syndrome is most prevalent between twenty and fifty years old, but the exact prevalence is unknown. [1, 2]

Clinical Perspective

The characteristic symptoms are tenderness, pain and oedema involving usually one of the joints unilaterally. [1, 2] Pain may radiate to the arm and shoulder and worsens by deep inspiration, torsional movements and sneezing. During exacerbations, even mild fever may develop. [1]

The diagnosis is based on increased tenderness after palpation of the affected joint, increased inflammatory parameters and imaging studies, mostly MRI and ultrasound. [1]

Imaging Perspective
A chest radiograph is used to exclude other pathology involving lungs, heart and pleura. [1, 2]

CT can demonstrate focal cartilage enlargement [2] and other pathology not apparent on plain x-ray involving lungs, heart, pleura and chest wall in detail.

Ultrasound is a great modality to screen for Tietze syndrome. Findings are focal hypo-echogenic parasternal cartilage with hyperaemia and oedematous infiltration of the surrounding soft tissue. [1, 3]

MRI demonstrates focal cartilage enlargement, high T2 signal as sign of oedema and vivid enhancement of the affected cartilage, subchondral bone and peri-articular structures. [2]

Outcome
Treatment is conservative with pain control using nonsteroidal anti-inflammatory drugs and application of local heat. Corticosteroid and lidocaine injections to the cartilage or intercostal nerve block can be used in refractory symptoms. [1]

Take-Home Message / Teaching Points
Radiography and CT are used to rule out other pathology. Ultrasound and especially MRI can accurately diagnose Tietze syndrome in patients with unilateral parasternal pain.