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The Rib Lesions of Rheumatoid Arthritis

1964; Radiological Society of North America; Volume: 82; Issue: 5 Linguagem: Inglês

10.1148/82.5.872

1527-1315

Meyer Alpert, Frieda Feldman,

Musculoskeletal synovial abnormalities and treatments

Although the synovial membrane is the most frequent site of the rheumatoid lesion, in recent years there has been considerable interest in the extra-articular and visceral manifestations of this generalized collagen disease. While the corneal complications (21) have been recognized since 1926 (19), there is now more evidence to implicate rheumatoid arthritis in lesions of the heart valves (4), pericardium (7), lung (11), and pleura (9). Because of their proximity to pannus formation, the articular ends of the tubular bones are the most frequent site of lytic changes. Extra-articular osseous alterations, however, have been demonstrated in the vertebral bodies (1), the pelvis (8), and the skull (16). In our experience the ribs may also be involved by rheumatoid arthritis in their extra-articular portions. Since these costal changes have not been adequately described in the literature, the findings in 8 cases demonstrating rheumatoid rib erosions will be presented. Review of the Literature The authors reviewed the medical literature from 1930 through 1962. In this period over 50 articles were published dealing with the roentgen manifestations of rheumatoid arthritis, but no author mentioned the erosions in the nonarticular portions of the ribs. Martel (12), however, did describe one patient with bone absorption at the “posterior ends of the ribs,” evidently at the costovertebral articulations. In addition, an article by Noetzli and Steinbach (13) on hyperparathyroidism referred to rib changes in rheumatoid arthritis, suggesting a possible relationship to steroid therapy. Neither article contained roentgenograms of the affected ribs. Clinical Material In the 8 patients with rib changes the average age was fifty-five years, with a range of thirty-six to sixty-nine. There were 5 women and 3 men. The average duration of arthritic symptoms was twenty years, with a minimum of fourteen and a maximum of thirty-two. None had complaints referable to the ribs. Their symptoms were due to peripheral joint involvement and consisted of pain, swelling, and stiffness. The physical findings included limitation of joint motion, flexion deformities, muscle atrophy, and ulnar deviation of the fingers. The erythrocyte sedimentation rate was elevated in all patients. A laboratory test for rheumatoid arthritis was carried out in 5 (sheep-cell agglutination or latex fixation) and was positive in all. Five of the 8 patients had received oral steroids at some time in the clinical course of their disease; 1 of the 5, however, had had only one month of corticoids. Two of the 8 patients had been given a limited number of intra-articular steroid injections. One patient had never received cortisone. Roentgen Findings In 7 of the 8 patients the rheumatoid rib lesions were visualized as either localized areas of flattening or erosions. The maximum length of the segmental flattening was 6 cm. The maximum length of the cup-like erosions was 9 mm., with a maximum depth of 4 mm. These changes were all confined to the superior borders of the posterior aspects of the third, fourth, and fifth ribs. The third rib was involved 11 times, the fourth rib 6 times, and the fifth rib twice. The lesions were bilateral in 7 of the 8 cases. The 1 patient (Case VIII) with unilateral lesions had involvement of both the third and fourth ribs. The most extensive costal lesions were seen in Case III. Here the posterior portion of the right third rib was destroyed almost completely for a distance of 6 cm. Three small lytic areas were also present in the left third and fourth ribs. Differential Diagnosis Segmental flattening of the superior aspect of a posterior rib (13) is occasionally observed as an anatomic variant, and this may mimic the rheumatoid lesion. A notch-like erosive change, however, has not been regarded as a normal finding.