2. CASE
• A 29 years old 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,” localized to the right side of
her anterior chest, and radiating to her back ipsilaterally.
The swelling was very firm, tender, and had appeared
spontaneously. She denied trauma, recent travel, or illnesses.
She denied fever, chills, malaise, or weight loss. She works as
a visual merchandiser but has had no change in her level of
physical activity.
3. • 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 or other changes to the
skin. The swelling was very firm and non-fluctuant. An
electrocardiogram and chest radiograph revealed no abnormalities. Her
basic lab work was within normal limits (CBC) 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 ketorolac and warm compresses. Upon
discharge she elected to continue ibuprofen, at increased doses, as well
as use warm compresses. She was also prescribed oxycodone 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.
4. INTRODUCTION
Tietze syndrome (also called chondropathia tuberosa or
costochondral junction syndrome) is a rare, inflammatory
disorder characterized by chest pain and swelling of the
cartilage of one or more of the upper ribs (costochondral
junction).
Costochondritis is distinguished from Tietze syndrome, a
condition also involving pain in the same area of the front of
the chest without swelling.
5. Tietze syndrome was first described in the medical literature
in 1921 by Alexander Tietze, a German surgeon.
Tietze's syndrome usually affects the upper ribs, especially the
second or third ribs. Costochondritis can affect any of the
costochondral joints, but most commonly the second to the
fifth ribs are affected.
The pain is aggravated by physical activity, movement, deep
inspiration, coughing or sneezing.
6. EPIDEMIOLOGY
Tietze's syndrome can present at any age but is most common
in those under the age of 40 years.
Tietze syndrome can occur in children, infants, and adults.
The ratio of men to women is 1:1.
In 80% of those with Tietze's syndrome, it is unilateral and
only one joint is affected.
7. ETIOLOGY
• The exact underlying cause of Tietze syndrome is currently
unknown.
• It often results from a physical strain or injury, such as
repeated coughing, sneezing, vomiting, or impacts to the
chest.
8. SYMPTOMS
• Chest pain and swelling.
• The pain of Tietze syndrome sometimes extends to the neck,
arms, and shoulders. The pain can be mild or severe, dull or
sharp. Some say it feels like being stabbed with a knife.
• Coughing, sneezing, exercise or other physical activity,
breathing deeply, laughing, wearing a seatbelt, hugging
someone, or even just lying down might make the pain
worse.
9. DIFFERENTIAL DIAGNOSIS
• Tietze syndrome can be hard to diagnose because the symptoms
are like those of other problems besides a heart attack. They can
seem like angina. They are also very similar to certain lung
problems, rheumatoid arthritis, and costochondritis.
• Certain forms of malignant lymphoma can cause chest pain and
swelling similar to that in Tietze syndrome.
• You might mistake the pain from Tietze syndrome for a heart
attack but there are differences: Tietze syndrome usually only
affects a small area of the chest while a heart attack covers the
whole chest. If you're having a heart attack, you may also be
short of breath, nauseous, and sweating.
10. DIAGNOSIS
A diagnosis of Tietze syndrome is made based upon a thorough
clinical evaluation, a detailed patient history, identification of
characteristic symptoms, and exclusion of other causes of
chest pain. A variety of tests including electrocardiogram, x-
rays, and biopsies may be performed to rule out more serious
causes of chest pain including cardiovascular disorders or
malignant conditions. Magnetic resonance imaging (MRI) can
show thickening and enlargement of affected cartilage.
11. TREATMENT
In some cases, pain resolves itself without treatment. Specific
treatment consists of rest, avoidance of strenuous activity, the
application of heat to the affected area, and pain medications
such as nonsteroidal anti-inflammatory drugs (NSAIDs) or a
mild pain reliever (analgesic). Local corticosteroid or lidocaine
injections directly into the affected area may be beneficial for
people who don’t respond to pain relievers. Usually the pain
subsides after several weeks or months, but the palpable
swellings may persist for some time.
