Tietze’s Syndrome in the emergency department: A rare etiology of atraumatic chest pain

doi:10.4236/crcm.2013.23056

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Vol.2, No.3, 208-210 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.23056

Tietze’s Syndrome in the emergency department: A

rare etiology of atraumatic chest pain

Lee Grodin1*, Gino Farina2

1Department of Emergency Medicine, State University of New York, Downstate Medica l Center, New York, USA;

*Corresponding Author: [email protected]

2Department of Emergency Medicine, Long Island Jewish Medical Center, New York, USA

Received 29 March 2013; revised 30 April 2013; accepted 15 May 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Tietze’s Syndrome is an uncommon disorder

that presents with painful, tender, non-suppura-

tive swelling of the anterior chest wall. We report

a case of a female patient who presented to the

emergency department with a chief complaint of

atraumatic chest pain and swelling of the ante-

rior chest wall. After a thorough history and

physical examination, as well as basic labora-

tory tests and chest radiography, she was di-

agnosed with Tietze’s Syndrome. The expedient

accurate diagnosis of Tietze’s Syndrome is im-

portant for the physical and emotional well-be-

ing of a patient, and avoids overlooking more

dangerous pathologies. T ietze’s Syndrome needs

to be considered in the differential diagnosis of

a patient presenting with spontaneous swelling

of the anterior ches t.

Keywords: Tietze’s Syndrome; Atraumatic

Chest Pain

1. INTRODUCTION

Chest pain is a frequent chief complaint in emergency

departments, and the underlying pathology ranges from

completely benign to imminently life-threatening. Among

the myriad possible etiologies are the confounding mus-

culoskeletal disorders, which account for 50% of benign

causes [1]. While frequently discussed and included in

differential diagnoses, they are often inappropriately con-

solidated and misunderstood. Tietze’s Syndrome (which

has also been referred to as Costosternal Syndrome, An-

terior Chest Wall Syndrome, Parasternal Chondrodynia,

Thoracochondalg ia, Chondrop athia Tubero se, and Costo-

chondral Junction Syndrome) is an uncommon muscu-

loskeletal pathology, which was first described in 1921

by Alexander Tietze [2-4]. The National Institutes of

Health lists it as a rare disease, indicating the limited

available information about the syndrome as well as its

possible rari t y [5].

While it is a benign, self-limited, chronic pain condi-

tion characterized by a localized swelling involving usu-

ally the second or third ribs, unrecognized it can mimic

malignancies, acute coronary syndrome, pneumonia, or

trauma [6,7]. The emotional and physical relief of an

accurate diagnosis is then delayed and the patient can

undergo an emotionally stressful and costly evaluation

for more serious disease [7,8]. The pain can be tremen-

dous. We present a young female patient with a classic

case of Tietze’s Syndrome. The diagnostic difficulty lies

in part to the absence of confirmatory laboratory or im-

aging tests, thus leaving the clinician reliant on the pa-

tient’s history and presentation.

2. CASE PRESENTATION

A 29 years old otherwise healthy woman presented

with localized right sided chest pain for approximately

three days and focal swelling over the same area for one

to two days. She described the pain as “aching,” local-

ized to the right side of her anterior chest, and radiating

to her back ipsilaterally. It was pleuritic and associated

with subjective shortness of breath, which she attributed

to her pain. It was minimally responsive to ibuprofen.

The swelling was very firm, tender, and had appeared

spontaneously.

She denied trauma, recent travel, or illnesses. She de-

nied fever, chills, malaise, or weight loss. She works as a

visual merchandiser but has had no change in her level of

physical activity.

One year ago, the patient reported she was diagnosed

with Lyme Disease after presenting with malaise and

Bell’s Palsy. After confirmatory serological testing, she

completed a course of antibiotics. At that time she also

L. Grodin, G. Farina / Case Reports in Clinical Medicin e 2 (2013) 208-210 209

underwent evaluation for thyroid dysfunction and fibro-

mylagia, neither of which was diagnostic and her symp-

toms were attributed to Lyme Disease. Her only surgery

was approximately three years ago when she underwent

a small bowel resection secondary to obstructive benign

tumors.

On physical exam the patient preferred to be still in

effort to minimize her pain. The only remarkable finding

was a tender swelling approximately 5 cm in diameter

over her right second and third costocartilages. There

was no discoloration (ecchymosis or erythema) or other

changes to the skin (Figure 1). The swelling was very

firm and non-fluctuant. An electrocardiogram and chest

radiograph revealed no abno rmali ties. H er basic lab wo rk

was within normal limits (CBC, CMP) and her ESR was

2.0 mm/Hour.

The diagnosis was discussed with the patient and her

partner, and various pain management strategies were

offered. In the emergency department she received ke-

torolac and warm compresses. Upon discharge she

elected to continue ibuprofen, at increased doses, as well

as use warm compresses. She was also prescribed oxy-

codone for break through pain.

During follow-up by telephone, the patient reported

she declined to ever seek treatment or further imaging,

and the pain persisted for two to three months, slowly

declining. She has since returned to work and is no

longer using any analgesics.

3. DISCUSSION

A timely diagnosis of Tietze’s Synd rome can expedite

the implementation of an effective treatment regiment,

avoid an anxiety-provoking and costly work up, and re-

duce the possibility of overlooking more serious under-

lying pathologies. Tietze’s Syndrome is rare and few

clinicians have significant experience with it. The etiol-

ogy is mysterious, however, its diagnostic profile has

been crystallizing over the last h alf century.

Figure 1. 29-year-old woman presenting with stereotypical

localized swelling in Tietze’s Syndrome on the anterior chest

wall.

The incidence of Tietze’s Syndrome is not well stud-

ied, but in 1976, a study of 320 patients with precordial

chest pain yielded almost a 10% incidence of Costoster-

nal Syndrome, including Tietze’s Syndrome [3]. It is

most commonly diagnosed in 20 to 50 year old patients,

but can strike young pediatric and elderly patients

[6,9,10]. There is a wide range of sex distribution re-

ported, ranging from equal to twice as common in fe-

males than males [6,7,11,12]. The onset of pain can be

sudden or gradual, and it is often pleuritic or aggravated

my movement [7,11,13]. Supporting the diagnosis is the

chronic, often relapsing and remitting course of Tietze’s

Syndrome and ruling out other possibilities by history,

physical, and imaging [11,14].

The location of the pain and the rarity of the syndro me

lay the foundation for a broad differential diagnosis.

While 70% of cases of Tietze’s Syndrome are unilateral

and affect one joint, it is important to consider neoplastic,

cardiac, respiratory, gastrointestinal, and other muscu-

loskeletal origins [1]. While swelling is considered a

hallmark of Tietze’s Syndrome, it may only indicate the

severity of disease [15]. Several cases of malignancy

misdiagnosed as Tietze’s Syndrome have underscored

the importance of making an accurate diagnosis [16-22].

In addition one must be wary of the possibility of con-

current cardiac pathology [23].

In recent decades imaging has become an invaluable

resource for clinicians, yet it is still not diagnostic of

Tietze’s Syndrome. While radiographs help minimize the

concern for bone pathology, they are generally com-

pletely normal. Computer tomography scanning, bone

scintigraphy, ultrasound, and magnetic resonance imag-

ing have shown more helpful distinctions. A 2008 study

recommends MRI and a 2010 r ev iew recommen d ed bo ne

scintigraphy and ultrasound as screening tests [11,15].

There have been some histological inquiries, but the

studies have thus far deemed histology to be unrevealing

or unimportant [3,6,12].

Treatment for Tietze’s Syndrome is supportive, with

the mainstay of NSAIDs and application of heat or cold

[13]. For refractory cases, corticosteroid injections may

be considered [15].

4. CONCLUSION

Tietze’s Syndrome is an idiopathic chronic pain con-

dition, which is rarely seen in emergency departments. It

presents with atraumatic chest pain and a focal swelling

of the anterior chest wall. Current epidemiology suggests

that its prevalence is highest among patients between 20

and 50 years of age. Accordingly it is important to con-

sider Tietze’s Syndrome and other musculoskeletal di-

agnoses in patients of this age range. Older patients pre-

senting with chest pain are more likely cardiac, pulmo-

nary, or neoplastic etiologies. The accurate diagnosis of

L. Grodin, G. Farina / Case Reports in Clinical Medicin e 2 (2013) 208-210

210

[11] Volterrani, L., et al. (2008) Magnetic resonance imagine

in Tietze’s Syndrome. Clinical and Experimental Rheu-

matology, 26, 848-853.

Tietze’s Syndrome provides the best platform for pain

management, reducing the time and cost of an unneces-

sary work up for other conditions while not overlooking

malignancies. It provides the patient with physical and

emotional comfort. While a thorough history and physic-

cal are essential for diagnosis, follow up is helpful to

ensure the disease course is consistent with Tietze’s

Syndrom e an d not suggestive of another pathology .

[12] Landon, J. and Malpas, J.S. (1959) Tietze’s Syndrome.

Annals of Rheumatic Disease, 18, 249-254.

doi:10.1136/ard.18.3.249

[13] Semble, E.L. and Wise, C.M. (1988) Chest pain: A rheu-

matologist’s perspective. Southern Medical Journal, 81,

64-68. doi:10.1097/00007611-198801000-00014

[14] Langford, C.A. and Mandell, B.F. (2012) Chapter 336.

Arthritis associated with systemic disease, and other ar-

thritides. In: Longo, D.L., et al., Harrison’s Principles of

Internal Medicine, The MacGraw-Hill Companies, Inc.,

New York, 2858 -2859.

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