Bull's head sign in the scintigraphy of a young female with recurrent chest pain.

Abstract

In this case we report a 38-year-old female patient with history of recurrent retrosternal chest pain lasting almost 5 years. Standard X-rays of chest and spine revealed no abnormalities. In a physical examination tenderness of anterior chest wall was observed, especially in sternoclavicular areas. SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome was taken into consideration despite of lack of typical skin lesions (acne, pustulosis). We decided to implement [99mTc]Tc-MDP scintigraphy. Increased osteoblastic activity (intense [99mTc]Tc-MDP) in manubriosternal and both sternoclavicular regions represents bull's head sign which is a rare finding, but pathognomonic to SAPHO syndrome. After a 3-month therapy with aceclofenac 100 mg, total remission was reached. If we rule out this rare condition like SAPHO based on lack of abnormalities in X-rays, the reason of symptoms could be still unrecognized. [99mTc]Tc-MDP scintigraphy is valuable to show even subclinical areas of involvement and to monitor treatment response in SAPHO syndrome. This case proved significant role of whole body scintigraphy to make diagnosis of SAPHO syndrome in patients with non-cardiac chest pain and lack of abnormalities in standard X-rays.