A 43-year-old man was admitted with pain in the left upper chest wall, which persisted for one month. A physical examination when done revealed swelling and tenderness over the left sternocostal joint.
A 43-year-old man who had stopped intense exercise (weight-lifting) of a long duration about one year ago was admitted with pain at the left upper area of the chest wall, which had persisted for one month. There was no history of surgery, trauma, drug ingestion, pulmonary or mediastinal infection. A physical examination when done revealed swelling and tenderness over the left sternocostal joint. No other sites of joint or bone involvement were present. A chest X-ray scan was requested. A CT scan was then performed, before and after an intravenous administration of an iodinated contrast medium, that demonstrated a poorly demarcated, mildly inhomogeneous soft tissue mass with an extension into the left anterior chest wall, and a displacement of the left pectoralis major muscle anteriorly. Inside the lesion, calcifications were visible. After an intravenous administration of an iodinated contrast medium, the lesion was enhanced homogeneously. The sternum was found to be thickened, with a slight destruction of the left sternic edge. A dilation of the first sternocostal junction was also present. An MRI demonstrated the presence of an abnormal and heterogeneous lesion that was located at the left first costosternal joint, with a radical extension of the high signal into the left pectoralis major muscle, probably due to the presence of fluid collection and surrounding edema. After an intravenous administration of gadolinium, there was a marked enhancement of the lesion located at the left first sternocostal joint.
Symptomatic arthritis can be the result of a trauma, joint overuse, infection, hyperostosis, post-menopausal conditions, metabolic disorders, and endocrinopathies, or secondary to an underlying arthropathy. Situations like surgery, trauma, pulmonary, pleural or mediastinal infections may lead to inflammation, cellulitis or abscesses of the chest wall. The risk increases with age, diabetes or in immunocompromised patients. Osteomyelitis is the most common cause for chest wall infections, which occurs as a result of an extraosseous extension, especially after a surgical medial sternotomy. Staphylococcus aureus, non-group A, beta-hemolytic streptococci and Streptococcus pneumonias are the most commonly involved gram-positive aerobic organisms. Gram-negative bacteria and anaerobes are increasingly frequent causes as a result of parenteral drug use and the rising number of immunocompromised hosts. Anaerobic infections are also more common in patients who have wounds of an extremity or who have gastrointestinal cancers. A possible spread of tuberculosis from the thoracic skeleton or pleural space, should be considered in the differential diagnosis, especially in immunocompromised hosts and in patients whose joints have been injected frequently with corticosteroids. Arthritis of the manubriosternal joint and upper sternocostal joints, as a part of ankylosing spondyitis, reactive arthritis, and arthritis associated with psoriasis and /or pustulosis palmoplantaris is very common in this group of patients. The sternum may be involved directly by primary tumors such as bronchogenic carcinoma, and breast carcinoma, or by metastases from prostate, thyroid, breast, lung or renal carcinomas. Radiation therapy may result in localized osteoporosis, sclerosis or aseptic necrosis.The SAPHO syndrome stands for Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis. The common site of skeletal lesions in this syndrome is the sternoclavicular area. The axial skeleton can occasionally be involved. The occurrence of ternocostal degenerative arthritis is very uncommon and can be the result of the transformation of this particular structure in a movable articulation joint because of abnormal usage, such as long-term exercise (weight-lifting in our case), or can be the result of a distant trauma. The clinical features of sternocostal degenerative arthritis include joint pain and stiffness, swelling, crepitus, low-grade synovitis, and loss of mobility. Osteoarthritis is typically characterized by a narrowing of the joint space and subchondral sclerosis, with small subchondral cysts seen on both sides of the joint, as well as the presence of osteophytes.
Sternocostal degenerative arthritis with intra-articular fluid collection.
Based on the provided chest imaging (including X-ray, ultrasound, and MRI/CT), the following primary features are observed:
Based on the clinical presentation (left anterior chest wall pain, swelling, and tenderness) and imaging findings, the following potential diagnoses are considered:
When caused by bacteria (e.g., Staphylococcus, Streptococcus) or Mycobacterium tuberculosis, there may be bone destruction or abscess formation. However, no significant bony destruction or obvious soft tissue abscess is observed on the current images.
Metastases from lung cancer, breast cancer, prostate cancer, etc. can involve the sternum. However, the imaging does not show obvious signs of malignancy (e.g., lytic or blastic lesions, soft tissue masses).
If accompanied by systemic symptoms or skin lesions (e.g., pustular lesions, psoriasis) or other arthritic symptoms, these should be considered. Currently, there are no more systemic manifestations or specific dermatological history apart from chest wall symptoms.
For patients with a history of long-term weight-bearing exercise (such as weightlifting) or repetitive chest wall stress/injury, degenerative changes can occur, including joint space narrowing and osteophyte formation.
Taking into account the patient's age (43 years old), long-term heavy weight training (presumably with repeated chest loading or trauma), chronic pain (1 month), absence of obvious systemic infection, and only mild degenerative changes on imaging, the most likely diagnosis is:
Degenerative (wear-and-tear) arthritis of the left costosternal joint.
To rule out infection, tuberculosis, or tumor, further tests such as serological examinations (white blood cell count, CRP, ESR, etc.) and pathological biopsy may be necessary. If there is a risk of tuberculosis or immunological disease, relevant pathogen detection should be conducted.
For degenerative arthritis or osteoarthritis, the main treatments include:
Additionally, regular joint flexibility exercises and thoracic spine extension exercises should be included to prevent joint adhesions and restricted mobility. If the patient has osteoporosis or poor cardiopulmonary function, the type and intensity of exercises should be individually tailored.
This report is a reference analysis based on the provided information and cannot replace an in-person consultation or specialist advice. If you have any questions, please consult a specialist or go to a local hospital for further examination and treatment.
Sternocostal degenerative arthritis with intra-articular fluid collection.
