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Ann Rheum Dis. 2007 September; 66(9): 1264–1266.
PMCID: PMC1955132

Crico‐thyroid perichondritis leading to sore throat in patients with active adult‐onset Still's disease

A review of 341 adult‐onset Still's disease (AOSD) patients noted that 69% of all reported cases1 and 84% (69/82) of our series2 displayed sore throat early in the disease course. Despite the presence of severe sore throat, physical examinations showed normal findings or only mild pharyngeal infection, and imaging studies (including computed tomography (CT) scans) of the neck were negative.1,2,3,4 The lesions responsible for sore throat in active AOSD patients have not yet been explored.

We performed magnetic resonance imaging (MRI) of the larynx5 in 6 active AOSD patients (3 females and 3 males; mean age 33.5 years; table 11)) presenting with sore throat and fulfilling the Yamaguchi criteria.6 Our aim was to identify the lesions responsible for sore throat in AOSD patients. Throat swabs for bacterial cultures were negative and serological tests for viruses were non‐diagnostic in all AOSD patients. Serum levels of C‐reactive protein (CRP) were elevated in all of our active AOSD patients. Three AOSD patients were available for MRI examination both at the active phase when presenting with sore throat, and at the remission phase (defined as the absence of systemic manifestation and sore throat within 6 months of effective therapy). The Ethics Committee of Clinical Research, Taichung Veterans General Hospital, approved this study protocol.

Table thumbnail
Table 1 Summary of clinical and MRI findings of 6 patients with adult‐onset Still's disease during sore throat

A brief summary of clinical and MRI findings of our 6 AOSD patients during sore throat was shown in table 11.. The T1‐weighted images showed increased thickness of soft tissue near the crico‐thyroid cartilage (case 1 and fig 1A1A),), and the post‐contrast T1‐weighted images demonstrated marked enhancement at the perichondral tissue (fig 1B1B).). In an AOSD patient presenting with odynophagia, the post‐contrast T1‐weighted image showed marked enhancement at the soft tissue near cricoid‐thyroid cartilages and the pharynx (case 5 and fig 1C1C).). Gallium‐67 scintography showed an increased uptake intensity at the corresponding region (fig 1D1D).). In a patient who had redness of the laryngeal mucosa shown by indirect laryngoscope, a T2‐weighted image illustrated increased signal intensity at the soft tissue surrounding the vocal cord (case 6). During a longitudinal follow‐up, the inflammatory signs shown by MRI markedly subsided (fig 1E, 1F1F),), paralleling clinical remission and the decrease in CRP (mean ± SD, 6.5 ± 4.8 mg/dl vs 0.1 ± 0.0 mg/dl).

figure ar65342.f1
Figure 1 MRI findings of the larynx in case 1 presented with left‐sided sore throat lasting for 2 weeks. (A) Axial, T1‐weighted image shows increased thickness of soft tissue near the left half of the thyroid cartilage ...

Discussion

There are no further image studies concerning the cause of sore throat in AOSD patients following negative findings of CT scans.1 We demonstrated high signal intensity with contrast enhancement over soft tissue surrounding crico‐thyroid cartilage and/or vocal cords in active AOSD patients presenting with sore throat. Perichondritis of crico‐thyroid cartilage and/or corditis may explain the sore throat, and the close proximity between the involved area and pharyngeal constrictors may lead to odynophagia. The evidence of inflammation was supported by an increase in the uptake intensity of Gallium‐67 citrate, which has a high affinity for inflammatory lesions.7 MRI changes of crico‐thyroid cartilage parallel clinical remission and the decrease in serum CRP levels in AOSD patients. Our results suggest that crico‐thyroid perichondritis, demonstrated by MRI, may precipitate the pathogenesis of sore throat in AOSD.

Abbreviations

AOSD - adult‐onset Still's disease

CRP - C‐reactive protein

CT - computed tomography

MRI - magnetic resonance imaging

Footnotes

Competing interests: None declared.

References

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5. Castelijns J A, Doornbos J, Verbeeten B, Vielvoye G J, Bloem J L. Magnetic resonance imaging of the normal larynx. J Comput Assist Tomogr 1985. 9919–925.925 [PubMed]
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