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Figure 1. The patient is a 62-year-old man who presented with a 27-year history of recurrent upper anterior chest pain. He had consulted many physicians, and numerous complete evaluations had been performed, without a conclusive diagnosis. Results of routine laboratory tests, including erythrocyte sedimentation rate and C-reactive protein level, were within normal ranges. HLA–B27, antinuclear antibodies, and rheumatoid factor were negative. The physical examination findings at the time of presentation were normal except for distention of the sternoclavicular joints. The patient reported that these joints had repeatedly become swollen for periods of several days during previous years. There were no abnormalities of the skin, nails, or eyes. On intensive questioning, the patient also reported having recurrent skin rashes restricted to the palms of the hands and soles of the feet. Radiography of the sternoclavicular joints revealed typical findings of SAPHO syndrome, with cortical thickening and expansion of the sternal ends of the clavicles (A) and sternoclavicular hyperostosis (B). The acronym SAPHO (synovitis, acne pustulosis, hyperostosis, osteitis) describes a clinical entity of musculoskeletal disorders, in particular hyperostosis involving the bones and joints of the anterior chest wall in association with various dermatologic conditions such as palmoplantar pustulosis or other patterns of psoriasis and severe acne. As this case illustrates, it may be underrecognized, because skin manifestations may be mild or absent and the courses of skin and bone manifestations are often not parallel. Awareness of this clinical entity and thorough history-taking and examination will allow correct and early diagnosis of the syndrome.

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