Sternocostoclavicular Hyperostosis: An Insufficiently Recognized Clinical Entity

Abstract

A 79-year-old male chronic hemodialysis patient with no history of central venous catheterization was referred to our hospital with progressive swelling of the left upper limb ipsilateral to a forearm arteriovenous fistula. Radiological assessments revealed marked hyperostosis in the ribs, sternum, and clavicles with well-developed ossification of the sternocostoclavicular ligaments. Such characteristic structural abnormalities and our failure to identify the left subclavian vein with contrast material despite the abundant dilated collaterals in the left shoulder area encouraged us to diagnose our patient with sternocostoclavicular hyperostosis (SCCH) complicated by central vein obstruction. The structural impact of the sternocostoclavicular region as a potential risk for inducing central vein obstruction and the diagnostic concerns of SCCH in this patient are also discussed.

Keywords: SAPHO syndrome; central vein obstruction; hemodialysis; sternocostoclavicular hyperostosis; vascular access.

Figure 1.

Conventional plain radiographs and left upper limb digital subtraction angiography. (A) A chest radiograph obtained 3 years earlier had already shown the widespread increased radiodensity in the bilateral sternocostoclavicular regions as well as marked left clavicular hyperostosis, neither of which had been investigated. (B) Similar skeletal findings were confirmed at the referral as well. (C) Digital subtraction venogram injected via the drainage vein of the left forearm arteriovenous fistula failed to demonstrate the left subclavian vein despite the abundant dilated collaterals in the left shoulder area.

Figure 2.

Thoracic computed tomography (CT) with contrast injection. A series of CT scans shown in alphabetical order (A to J) reveals marked hyperostosis in the ribs, sternum, and clavicles with well-developed ossification of the sternocostoclavicular ligaments. Note that the left clavicle and manubrioclavicular joint are predominantly affected. Despite the successful identification of the right subclavian vein (narrow arrows in B to D) and left innominate vein (arrowheads in G to J) with the contrast material, the left subclavian vein could not be visualized sufficiently in the corresponding area (middle arrows in D and E), although we did notice collateralization in the surrounding thoracic region (wide arrows), which was also identified in a coronal reconstructed image (K).