Costochondral Calcification
| |
| Costochondral Calcification | |
|---|---|
| Causes | Idiopathic, familial chondrocalcinosis, older age, hyperthyroidism, porphyria, Tietze syndrome and malignancy (if focal) |
| Clinical Features | Often incidental and asymptomatic |
| Tests | XR or CT. TSH and free T4, calcium and phosphate, renal function tests, vitamin D levels. If relevant then also CRP/ESR and PTH |
Costochondral calcification is the radiologic appearance of calcium deposition within the cartilaginous regions of the rib cage where the ribs articulate with the sternum, which are usually invisible on plain film imaging.
Although such calcification is common in older adults, it can also occur in younger individuals, typically termed āpremature calcification.ā Premature calcification, defined by many studies as calcification of costochondral cartilage in persons aged 40 years or younger, may be asymptomatic but is often linked to a range of endocrine, metabolic, traumatic, and occasionally malignant processes. Recognizing this phenomenon is important for clinicians because it can prompt a thorough investigation for potential underlying pathologies.
Terminology
The term calcification is a misnomer, and should more correctly be termed costochondral ossification.
Anatomy and Pathophysiology
The thoracic cage consists of 12 paired ribs, most of which articulate with the sternum via costal cartilages. These costal cartilages provide both structural stability and flexibility, allowing the rib cage to expand and contract during respiration. Calcification typically begins with the secretion of alkaline phosphatase from chondrocytes within the cartilage. The resultant increase in phosphate ions, combined with free calcium, leads to the formation of calcium salts that deposit in the cartilaginous matrix. In older adults, costochondral calcification is considered a normal degenerative change and is often incidentally noted on imaging. In younger adults, however, such calcification may indicate an abnormal metabolic or endocrine state.
There are gender related patterns of calcification, they are so specific that these patterns are used forensically to assist in gender determination. [1]
- Men show calcification at the periphery of the cartilage, contouring the upper and lower margins of the cartilage.
- Women have central tongue like calcifications, called a central lingual ossification pattern.
There are other patterns like central globular that are not sex-dependent.
Epidemiology and Risk Factors
Studies have reported wide-ranging prevalence estimates (0 to 100 percent) for costochondral calcification in the general population, and this prevalence typically increases with age. It occurs earlier in women than men, with 15% of women having calcification in the second decade compared to only 4% of men. By the sixth decade of life, a large majority of individuals exhibit some calcification.
Many published series rely on imaging that is performed for other clinical reasons, making it difficult to ascertain the precise prevalence in otherwise healthy young adults. Nevertheless, a consistent observation is that premature calcification of costochondral cartilage is uncommon and, when identified, should prompt consideration of underlying metabolic, endocrine, or structural abnormalities.
A number of risk factors have been associated with costochondral calcification in general, including advancing age and female sex. In studies that specifically examine premature calcification, female sex also appears to confer a higher risk, with some authors suggesting that endocrine or hormonal influences may play an important role in this population. Menstrual disorders have been linked to early calcification in a subset of patients, possibly related to systemic hormonal dysregulation. Additional factors such as metabolic syndrome, hyperglycemia or diabetes, and certain lifestyle patterns (e.g., strenuous exercise) have also been proposed as contributors in isolated studies.
Aetiology
Costochondral calcification is common with increasing age. However premature calcification has been reported in association with several pathologies.
- Hyperthyroidism is frequently cited because excess thyroid hormone can accelerate skeletal metabolism and promote early cartilage calcification.
- Familial chondrocalcinosis, which is often caused by abnormal calcium pyrophosphate deposition, sometimes presents in younger individuals with atypical sites of calcification, including the costochondral junctions.
- Porphyria, though this link remains rare.
- Wilson's disease
- Haemochromatosis
- Chronic kidney disease
- Some forms of trauma and repeated microtrauma have also been implicated.
- Malignancy
- Primary costal cartilage tumor such as chondrosarcoma or metastatic disease (e.g., from breast cancer), should be considered in the presence of local destruction, unexplained weight loss, or other systemic findings.
- Tumours releasing a PTH like substance
- Rare congenital diseases such as adrenogenital syndrome or keutel syndrome
- Tietze syndrome is a rare but benign inflammatory process affecting the costosternal junction
In many cases, no underlying cause is identified, and the designation of āidiopathic premature costochondral calcificationā is used.
Clinical Features
Calcification in younger individuals may be an incidental finding on a chest radiograph or computed tomography (CT) scan performed for another reason. When symptoms occur, patients may complain of localized chest wall pain, tenderness, or swelling. However it is unclear if the calcification is incidental to the pain. The clinical presentation often reflects the underlying diagnosis rather than the calcification itself; for example, hyperthyroidism might present with weight loss, heat intolerance, palpitations, or tremors, whereas malignancy might cause weight loss, systemic symptoms, or a palpable mass. If calcification is extensive or associated with degenerative changes, it may contribute to chest discomfort or mechanical pain.
Diagnosis
Thorough clinical evaluation is warranted in young patients with premature costochondral calcification. The literature is unclear as to what exactly should be defined as premature, but the most common limits are under 30 and under 40. A 2023 review of the literature determined that a cut off of 40 should be used due to low prevalence below that age.[2]
A detailed history should probe for trauma, familial predispositions, endocrine disorders, and systemic features of malignancy. Examination should include assessment for dysmorphia, cardiovascular, respiratory, abdominal, and musculoskeletal examinations.
Laboratory investigations: The 2023 review recommends as an initial screen to do creatinine, electrolytes, LFTs, FBC, calcium and phosphate, TSH and T4, vitamin D, and PTH. If clinically relevant then also test urine porphobilinogen, ESR, CRP, and ANA.
Advanced imaging with CT can provide additional detail, particularly if malignancy or complicated structural changes are suspected. Ultrasound of the costal cartilages may also be performed in certain reconstructive surgical planning or to identify subtle calcifications not easily visualized on plain radiography.
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PA Lumbar Spine in a 34 year old woman showing incidental premature costochondral calcification. She also has a partially sacralised L5 -
Lateral view also showing calcification
Management
Treatment depends primarily on the underlying cause. Patients found to have hyperthyroidism may require medical therapy (e.g., antithyroid medications or radioactive iodine) to control thyroid hormone levels and potentially slow disease progression. Metabolic disturbances such as chronic kidney disease and related calcium-phosphate imbalances also require specific interventions. Familial chondrocalcinosis is often managed supportively with anti-inflammatory medications to control symptomatic flares. Idiopathic cases, in which no root cause is identified and the patient is asymptomatic, can be observed clinically with periodic follow-up. Pain management, when needed, may include nonsteroidal anti-inflammatory drugs (NSAIDs) or local injections, particularly in inflammatory conditions like Tietze syndrome. Surgical intervention is rarely indicated unless there is an associated neoplasm or significant structural deformity of the chest wall.
Further Resources
Videos
References
- ā RejtarovĆ”, Olga; Hejna, Petr; Rejtar, Pavel; BukaÄ, Josef; SlĆžovĆ”, DĆ”Å”a; Krs, Otakar (2009-10). "Sexual dimorphism of ossified costal cartilage. Radiograph scan study on Caucasian men and women (Czech population)". Forensic Science International. 191 (1ā3): 110.e1ā110.e5. doi:10.1016/j.forsciint.2009.06.009. ISSN 0379-0738. Check date values in:
|date=(help) - ā Seng, Jun Jie Benjamin; Kho, Zhen-Bing Christine; Kaur, Navpreet (2024-12-08). "Premature Calcification of Costochondral Cartilage: A Scoping Review of the Literature". Cureus. doi:10.7759/cureus.75328. ISSN 2168-8184.
Literature Review
Literature Review
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