The first case of 2015 is intended to wake you up after the holidays. The patient is a 68-year-old man who came to our institution last October with pain in the chest and skin lesions. Is the chest normal?
If not, where is the abnormality? Check the images below, leave your thoughts in the comments section and come back on Friday for the answer.
Findings: PA chest shows a rounded haziness at the level of the first costo-chondral junctions (arrows), more evident on the right side. The lateral view only shows degenerative changes in the dorsal spine.
CT shows marked sclerosis of the proximal clavicles, first costo-chondral junction (A, C arrows) and sternal manubrium (B, arrows). The patient also had sacroileitis (D, arrows). On clinical examination, there were pustulous lesions in the sole of the feet.
This combination of findings is highly suggestive of SAPHO syndrome (synovitis, acne, palmoplantar pustulosis, hyperostosis and osteitis).
Final diagnosis: SAPHO syndrome
Congratulations to Ivan, who was the first to make the correct diagnosis.
Teaching point: I know this case is difficult and unusual, but we saw it only three months ago (See the date in the CT study). Sometimes we have to be aware that unusual cases can cross our path and be ready to diagnose them.
Happy N. Year Professor..
Here’s what I think:
In upper pulmonary zones We can see some mild fironodular opacification and the a-p tracheal diameter is quite big inadequately to the sd diameter- maybe the patient has COPD?
The other thing is, what seems to be enlarged/ swollen costal cartilages of the first ribs.. To make better ddx would be good to know, what type of pain and skin lesions this patient has.
Plus the degeneration of thoracic spine is quite obvious
The location is not typical for Tietze disease
Patient has pain in the front, the back and the lumbar spine. Will tell you the type of skin lesions on Wednesday.
Happy New Year.
The skin lesions are pustules.
Psoriatic lesions too?
Asymetric osteophytes could indicate psoriatic spondylitis…
any next hint?
Lesions located in the soles of the feet.
Rheumatoid arthritis ?
What makes you think that?
i am wrong …. SAPHO syndrome
Picture of granuloma. RH A granuloma
I would go with pustular psoriasis with hypertrophy and sclerosis of the manubrium.
I agree with SAPHO..
Bronchial involvement in RUL and tracheomalacia in psoriasis disease.
Alternative diagnosis: right fifth rib may show signs of osteitis , in this case, SAPHO syndrome should be suspected even though it is typical of pediatric patients.
HNY drs pepes 😉
This patient is on a cronical steroid treatment, which can explain the thoracic modifications: ginecomasty,bone mass loss with aberrant exostosis of the 1st ribs, posibly modifications in the lumbar spine as well. Psoriasis maybe the cause of steroid treatment.
….la patologia è a carico della parete toracica…..si osserva iperostosi dell’arco anteriore della 1 costa di dx e di sx, con rarefazione osteitica della 4 costa di dx….stessa disomogeneità strutturale a carico dei corpi vertebrali e dell’arco anteriore della 2 costa sx….l’associazione con acne e pustole, coincide con eventuale SAPHO sindrome, come giustamente suggerito…..
Better late than never…
….sono appena tornato da S.Domingo…..Prospero ano nuevo y prosperidad, magico Professore…..ero in dubbio con la S.di Giano( iper-IGE), che si manifesta con pustole diffuse….all’areooprto di Madrid non ho trovato magliette “blu-grana” x il mio nipotino ed ho optato x quella della Nazionale spagnola….hasta la victoria siempre !!!!