Costochondritis or Heart Problem?

Costochondritis is an inflammation of the junctions where the upper ribs join with the cartilage that holds them to the breastbone or sternum. The condition causes localized chest pain that you can reproduce by pushing on the cartilage in the front of your ribcage. Costochondritis is a relatively harmless condition and usually goes away without treatment. The cause is usually unknown.
 

• Costochondritis (with unknown cause) is a common cause of chest pain in children and adolescents. It accounts for 10-30% of all chest pain in children. Annually, doctors evaluate about 650,000 cases of chest pain in young people 10-21 years of age. The peak age for the condition is 12-14 years.
  
• Costochondritis is also considered as a possible diagnosis for adults who have chest pain. Chest pain in adults is considered a potentially serious sign of a heart problem by most doctors until proven otherwise. Chest pain in adults usually leads to a battery of tests to rule out heart disease. If those tests are normal and your physical exam is consistent with costochondritis, your doctor will diagnose costochondritis as the cause of your chest pain. It is important, however, for adults with chest pain to be examined and tested for heart disease before being diagnosed with costochondritis. Often it is difficult to distinguish between the two without further testing. The condition affects females more than males (70% versus 30%). Costochondritis may also occur as the result of an infection or as a complication of surgery on your sternum.
  
• Tietze syndrome is often referred to as costochondritis, but the two are distinct conditions. You can tell the difference by noting the following:
  
  
  • Tietze syndrome usually comes on abruptly, with chest pain radiating to your arms or shoulder and lasting several weeks. Tietze syndrome is accompanied by a localized swelling at the painful area (the junction of the ribs and breastbone).

Costochondritis Causes

Costochondritis is an inflammatory process but usually has no definite cause. Repeated minor trauma to the chest wall or viral respiratory infections can commonly cause chest pain due to costochondritis. Occasionally, costochondritis as a result of bacterial infections can occur in people who use IV drugs or who have had surgery to their upper chest. After surgery, the cartilage can become more prone to infection, because of reduced blood flow in the region that has been operated on.

Different types of infectious diseases can cause costochondritis.

• Viral: Costochondritis commonly occurs with viral respiratory infections because of the inflammation of costochondral junctions from the viral infection itself, or from straining from coughing.
  
• Bacterial: Costochondritis may occur after surgery and be caused by bacterial infections.
  
• Fungal: Fungal infections are rare causes of costochondritis.

Costochondritis Symptoms

Chest pain associated with costochondritis is usually preceded by exercise, minor trauma, or an upper respiratory infection.

• The pain usually will be sharp and located on your front chest wall. It may radiate to your back or abdomen and is more common on your left side.
  
• The most common sites of pain are your fourth, fifth, and sixth ribs. This pain increases as you move your trunk or take deep breaths. Conversely, it decreases as your movement stops or with quiet breathing.
  
• The reproducible tenderness you feel when you press on the rib joints (costochondral junctions) is a constant feature of costochondritis. Without this tenderness, a diagnosis of costochondritis is unlikely.
  
• Tietze syndrome, on the other hand, exhibits swellings at the rib-cartilage junction. Costochondritis has no noticeable swelling. Neither condition involves pus or abscess formation.
  
• Tietze syndrome usually affects the junctions at the second and third ribs. The swelling may last for several months. The syndrome can develop as a complication of surgery on your sternum months to years after the operation.
  
• When costochondritis occurs as a result of infection after surgery, you will see redness, swelling, or pus discharge at the site of the surgery.

• When to Seek Medical Care

  Call the doctor for any of the following symptoms:
  • Trouble breathing
    
  • High fever
    
  • Signs of infection such as redness, pus, and increased swelling at the rib joints
    
  • Continuing or worsening pain despite medication
  Go to a hospital's emergency department if you have difficulty breathing or any of the following symptoms occur. These symptoms are generally not associated with costochondritis:
• High fever not responding to fever-reducers such as acetaminophen (Tylenol) or ibuprofen (Advil)
  
• Signs of infection at the tender spot such as pus, redness, increased pain, and swelling
  
• Persistent chest pain of any type associated with nausea, sweating, left arm pain, or any generalized chest pain that is not well localized: These symptoms can be signs of a heart attack. If you are not sure what is causing your condition, always go to the emergency department.

• Exams and Tests

  Costochondritis does not lend itself to diagnosis by tests. Personal history and physical exam are the mainstays of diagnosis. Tests however are sometimes used to rule out other conditions that can have similar symptoms but are more dangerous, such as heart disease.
  
• The doctor will seek to reproduce tenderness over the affected rib joints, usually over the fourth to sixth ribs in costochondritis, and over the second to third ribs in Tietze syndrome. In costochondritis with unknown causes, there is no significant swelling of costochondral joints.
  
• There is swelling as well as tenderness of the rib-cartilage junctions in Tietze syndrome. Although some doctors use the terms costochondritis and Tietze syndrome interchangeably, Tietze syndrome has a sudden onset without any preceding respiratory illness or any history of minor trauma. In Tietze syndrome, there is frequently radiation of pain to arms and shoulders as well as pain and tenderness associated with swelling at the spot that hurts.
  
• Blood work and a chest X-ray are usually not helpful in diagnosing costochondritis. However, after sternum surgery, or for people at risk for heart disease, doctors will be more likely to do tests if you have chest pain and possible costochondritis to be certain you do not have any infection or other serious medical problems.
  
  
  • They will look for signs of infection such as redness, swelling, pus, and drainage at the site of surgery.
    
  • A more sophisticated imaging study of the chest, a gallium scan, is used to check for infection. It will show increased uptake of the radioactive material gallium in an area of infection.
    
  • In cases of possible infection, the white blood cell count may be elevated.
    
  • Chest X-ray should be obtained if pneumonia is a suspected cause of chest pain.
    
  • ECG and other tests will be done if a heart problem is being considered.
• Costochondritis is a less common cause of chest pain in adults but one that occurs fairly frequently in people who have had cardiac surgery. The diagnosis can only be reached after excluding more serious causes of chest pain that are related to the heart and lungs. The appropriate studies, such as ECG, chest x-rays, blood test for heart damage (cardiac enzymes and troponin levels), and other studies will be done as indicated. Any chest pain in adults is taken seriously and not ignored. If you are concerned, consult with your doctor.

• Self-Care at Home

• Treatment involves conservative local care with careful use of nonsteroidal antiinflammatory medications such as ibuprofen (Advil, Motrin) or naproxen (Aleve) as needed.
  
• Local heat or ice may be helpful in relieving the symptoms.
  
• Avoid unnecessary exercise or activities that make the symptoms worse. Avoid contact sports until there is improvement in symptoms, and then return to normal activities only as tolerated.

• Medications

  • Costochondritis responds to nonsteroidal antiinflammatory medications such as ibuprofen (Advil or Motrin) and naproxen (Aleve).
    
  • You may be given a local anesthetic and steroid injection in the area that is tender if normal activities become very painful and the pain does not respond to medications.
    
  • Infectious (bacterial or fungal) costochondritis should be treated initially with IV antibiotics. Afterward, antibiotics by mouth or by IV should be continued for another two to three weeks to complete the therapy.

  Surgery

  Surgical removal of the sore cartilage may be required if there is no response to medical therapy. Your doctor will refer you to a surgeon for consultation should this option be considered necessary.

  Next Steps

  Follow-up

  You should see a doctor during recovery, and then once a year. Infectious costochondritis requires long-term, close follow-up.

  Prevention

  Because inflammatory costochondritis has no definite cause, there is no good way to prevent it.

  Outlook

  Noninfectious costochondritis will go away on its own, with or without antiinflammatory treatment. Most people will recover fully.
  Infectious costochondritis responds well to IV antibiotics and surgical repair, but recovery may take a long time.
  source:Pain Management Health Centre