Sternoklaviküler septik artrit ve osteomiyelit

Özet

Sternoklaviküler septik artrit ve komşu osteomiyelit, özellikle bakteriyemi riski veya diyabet/immünsüpresyonu olan kişilerde ön göğüs duvarı ağrısı ve şişlikle ortaya çıkabilir. Kontrastlı BT, eklem çevresi kemik erozyonunu, göğüs duvarı flegmonunu ve retrosternal/mediastinal yayılımı haritalar; erken kemik iliği enfeksiyonunda MR daha duyarlıdır. Eklem aralığı genişlemesi, klavikula-manubrium erozyonları ve kontrastlanan çevre inflamasyonu birlikte olduğunda enfeksiyon lehine güçlü bir örüntü oluşur. Tanının gecikmesi kemik yıkımına, göğüs duvarı apsesine veya mediastinite ilerlemeye izin verebilir.

Faz ve pencere

Portal tanısal

İntravenöz kontrast sonrası sternoklaviküler eklem çevresinde sinovyal/yumuşak doku kontrastlanması, sıvı koleksiyonunun çevresel boyanması, göğüs duvarı flegmonu ve retrosternal yayılım aranır; medial klavikula ve manubrium erozyonları kemik algoritmasında eş zamanlı değerlendirilir.

Kontrastsız

BT’de sternoklaviküler eklem efüzyonu, komşu kemik erozyonları ve çevre yumuşak doku tutulumuyla enfeksiyonun yayılımı değerlendirilebilir.

Önerilen pencereler: Kemik (G 1800 / M 400), Yumuşak doku (G 400 / M 40), Mediasten (G 350 / M 50).

BT bulguları

• Sternoklaviküler eklem aralığında efüzyon ve çevresindeki kapsüler genişleme
• Medial klavikula ve karşı manubrium eklem yüzlerinde düzensiz erozyon veya kortikal destrüksiyon
• Eklem çevresi yağ planlarında kirlenme ve pektoralis/SCM komşuluğuna uzanan flegmon
• Merkezi düşük atenüasyon ve çevresel kontrastlanma gösteren göğüs duvarı apsesi
• Retrosternal koleksiyon ya da inflamasyonun üst mediastene devam etmesi
• Klavikula ve manubriumda kemik erozyonu, destrüksiyon ve osteoskleroz görülebilir.
• Komşu pektoral kaslarda apse veya yaygın yumuşak doku tutulumu görülebilir.

Normalde

Normal sternoklaviküler eklem aralığı dar ve düzenlidir; medial klavikula ile manubriumun karşılıklı korteksleri kesintisizdir ve eklem çevresi yağ planları temiz görünür. Sağ ve sol eklemleri aynı aksiyel seviyede kıyasla; enfeksiyonda eklem sıvısı/genişlemesi, iki karşılıklı kemik yüzündeki erozyon ve çevre yumuşak doku kontrastlanması normal asimetriden ayrılır.

Ayırıcı tanı

Osteoartrit, dejeneratif eklem değişiklikleri ve yapısal bozulmalarla seyrederek enfeksiyon bulgularından farklılaşır.

SAPHO/steril osteit

hiperostoz ve skleroz daha yaygındır; koleksiyon ve çevresel kontrastlanan apse tipik değildir.

Medial klavikula metastazı ayırıcı tanıda düşünülmelidir; sternoklaviküler bölgede kemik yıkımı ve yumuşak doku kitlesi malign kemik lezyonlarında da görülebilir, bu nedenle bu bulgular tek başına enfeksiyonu kanıtlamaz.

Tofüslü gut sternoklaviküler eklemi tutabilir; üst manubrium ve klavikulalarda litik, kortikal destrüktif lezyonlar oluşturarak başka patolojileri taklit edebilir ve eklem aspiratında monosodyum ürat kristallerinin gösterilmesi tanıyı destekler.

Tuzaklar

• Erken enfeksiyonda kortikal erozyon henüz belirgin olmayabilir; tek başına kemik penceresinin sakin olması eklem çevresi yumuşak doku inflamasyonunu dışlamaz.
• BT kemik yıkımı ve anatomik yayılımı gösterse de erken kemik iliği ödemi için duyarlılığı sınırlıdır; klinik kuşku sürüyorsa MR daha iyi değerlendirme sağlar.
• Eklem aralığı dejenerasyonda daralabilir, enfeksiyonda ise genişleyebildiği gibi daralmış da görülebilir; tanı için kemik ve yumuşak doku bulgularının birlikte değerlendirilmesi gerekir.
• Enfeksiyon retrostrenal alana ve mediastene uzanabilir; bu yayılımın varlığı ve derinliği değerlendirilmelidir.

Kendini dene

1. Ön göğüs duvarı hassasiyetinde sternoklaviküler eklem efüzyonu, iki eklem yüzünde erozyon ve çevre flegmon görülüyor. En olası tanı nedir?

   • Septik artrit
   • Osteoartrit
   • SAPHO sendromu
   • Medial klavikula metastazı
   Cevabı göster

   Septik artrit. Eklem efüzyonuna karşılıklı erozyon ve çevresel flegmonun eşlik etmesi enfeksiyon örüntüsüdür. Osteoartritte daralma ve osteofit, SAPHO'da hiperostoz/skleroz; metastazda medüller odak ön plandadır.

2. Sternoklaviküler eklemden retrosternal koleksiyona devamlılık gösteren kontrastlanan çevre dokulu sıvı odağı saptanıyor. Hangi komplikasyon tarif edilmelidir?

   • Retrosternal apse
   • Eklem osteofiti
   • Klavikula varyantı
   • Sternal foramen
   Cevabı göster

   Retrosternal apse. Eklem enfeksiyonundan retrosternal alana uzanan çevre kontrastlanmalı sıvı odağı apse yayılımını gösterir. Osteofit kemik çıkıntısıdır; anatomik varyant ve foramen koleksiyon oluşturmaz.

İlgili konular

• Göğüs duvarı flegmonu ve apsesi
• Kaburga osteomiyeliti

Kaynaklar

Bu sayfadaki 36 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 11 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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