Tietze's syndrome presenting as enthesitis diagnosed by ultrasound: A case report.

Tietze's syndrome (TS) is an inflammatory disorder characterised by painful, non-suppurative swelling in the sternocostal or sternoclavicular joint. The aetiology of TS is unknown. Herein, we described a case of isolated enthesitis in the sternocostal joint in a 42-year-old male patient whose clinical course led to the diagnosis of TS. A 42-year-old male Japanese patient (HLA-B27 negative) presented with chronic anterior chest wall pain. Mild swelling and tenderness were found in the right, third sternocostal joint (rt.3STCJ). No other arthralgia was present. Ultrasonography (US) of the rt.3STCJ showed hypoechoic thickening and power Doppler signal in the anterior radiate sternocostal ligament with mild synovial hypertrophy of the STCJ. US also depicted cortical bone erosion at the sternum with neovascularisation. Magnetic resonance imaging with T2-weighted short-tau inversion recovery showed high signal intensity in the bone marrow of the sternum and adjacent soft tissue around the rt.3STCJ. Based on these findings, TS with the enthesitis in the rt.3STCJ was diagnosed. The patient received a US-guided corticosteroid injection, and the symptoms completely resolved 10 months later. Enthesitis may cause TS. US is a readily available, sensitive imaging technique useful for diagnosing TS.

The efficacy of oral corticosteroids for treatment of Tietze syndrome: A pragmatic randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: Tietze syndrome is a rare form of chest wall costochondritis with joint swelling which can cause significant chest pain and decline in ability of daily activities. There is no standardized treatment protocol. The aim of this study was to assess the efficacy of adding oral steroids in addition to other non- steroidal treatment in improvement of pain and quality of life (QOL) in patients with Tietze syndrome. METHODS: Forty patients with Tietze syndrome were randomly divided into two treatment groups: (1) One week of prednisolone 40 mg daily followed by 1 week of prednisolone 20 mg daily followed by 1 week of 10 mg with 3 weeks of non-steroidal anti-inflammatory drug (NSAID) treatment (n = 20); (2) three weeks of NSAID treatment only (n = 20). A symptom questionnaire was used to rate the major symptoms of Tietze syndrome and costochondritis: Numeric rating scale (NRS) for pain on a scale of 0 (no pain) to 10 (severest pain); the resulting global symptom score was used to evaluate the efficacy of treatment with assessment of joint swelling resolution. The EQ-5D-5L instrument for measurement of QOL was used. Assessments were made on intention to treat basis at baseline and at 1, 2 and 3 weeks followed by a medium term follow period after treatment cessation. The trial was registered at www.isrctn.com ISRCTN11877533. RESULTS AND DISCUSSION: There was a significant drop in mean NRS pain scores between the groups at 1, 2 and 3 weeks in favour of the steroid group (46.8% vs. 17.7%; p < 0.001, 56.3% vs. 35.8% p < 0.001 and 65.4% vs. 46.7% p < 0.001 respectively). There was a 25.8% (95% CI 13.2-38.8) difference in mean NRS score drop at a median of 6.5 months after treatment cessation in favour of the steroid group over the NSAID only group. Only three cases of mild GIT upset in the steroid group and two cases of mild nausea were reported in the NSAID group. There was an improvement in QOL using the median EQ-5D-5L scoring at 3 weeks in favour of the steroid group 7 (7, 8) versus 10 (8.5-11), (p < 0.001). The improvement in pain scoring and QOL did not correlate with improvement in joint swelling at 3 weeks after treatment with 2/20 (10%) in the steroid arm versus 1/20 (5%) in NSAID arm having an obvious improvement (p = 0.393). WHAT IS NEW AND CONCLUSION: In this study, addition of short-term oral corticosteroids showed a clear benefit for use at 1, 2 and 3 weeks in improvement of pain and QOL in patients with Tietze syndrome. This difference was maintained at mid-term follow up after treatment cessation. This facilitates the advantage of using steroids as well as excluding their side effects for an accepted timeframe.

Slipping rib syndrome: A clinical and dynamic-sonographic entity. A serial cases report.

BACKGROUND: Slipping rib syndrome (SRS) consists of false or floating rib hypermobility, which can force the ribs to come into contact with each other. OBJECTIVE: We aimed to examine each case by dynamic ultrasound to determine their ultrasound characteristics and analyze the clinical features of patients with SRS in order to better manage and follow them up. METHODS: Retrospectively, we collected 14 case series presenting to SRS between June 2016 and September 2018. The diagnosis was clinical and confirmed by dynamic ultrasound maneuvers. RESULTS: The mean age was 35.00 ± 10.66 years and 64.29% was male. The pain mechanism was caused by repetitive movements or a traumatic event. Dynamic ultrasound was considered a very useful tool for the diagnosis. Different conservative treatments were applied in most cases. Eco-guided infiltration was also an option. CONCLUSIONS: SRS should initially be based on a clinic suspicion in order to achieve a correct diagnosis and management. It is an underdiagnosed syndrome, so these case series contribute to our knowledge regarding this syndrome.

Costocondritis y espondilitis diferidas por Candida en paciente post-COVID tratado previamente con corticoides, antibióticos y tocilizumab / Delayed Candida costochondritis and spondylitis in a post-COVID patient previously treated with corticosteroids, antibiotics, and tocilizumab

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External application of two unrestricted herbal medicines to treat costochondritis in a young collegiate athlete: A case report.

Costochondritis (ChC), especially chronic ChC, typically manifests as spontaneous vague pain in anterior chest area and often occurs in adolescents for unknown reasons; it has prevented many collegiate athletes from participating in physical training and competitions. A 21-year-old female collegiate taekwondo athlete suffering from chronic chest pain was sent by her coaches for diagnosis and treatment. Seated motion palpation was used to identify spontaneous and motion-involved pain areas. Palpation in the supine position was used to initially rule out breast diseases. X-ray, electrocardiogram, and cardiac Doppler ultrasound were used in conjunction with myocardial enzyme testing to rule out lung and cardiovascular diseases. The patient was treated using herbal medicines applied via an external patch. The medicine was comprised of Rhizoma Corydalis and borneol, and the treatment lasted for seven weeks. For five weeks patches were applied at a frequency of two or three times per day, followed by a two-week period of once per day. The patient reported that the pain was relieved after two weeks of external herb use, and the autonomic chest pain had resolved. Re-examination after one month showed that her upper limb range of motion was close to normal, and her psychological burden had almost disappeared. It is possible to seek more active medicinal treatment and more practical external products for young athletes who is suffering chronic ChC that affects the sport training and competitive performances.

Imaging in the Evaluation of Chest Pain in the Primary Care Setting, Part 2: Sources of Noncardiac Chest Pain.

Chest pain is a common presenting complaint in the primary care setting. Imaging plays a key role in the evaluation of the multiple organ systems that can be responsible for chest pain. With numerous imaging modalities available, determination of the most appropriate test and interpretation of the findings can be a challenge for the clinician. In this 2-part series, we offer resources to guide primary care physicians in the selection of imaging studies and present the imaging findings of various causes of nonemergent chest pain. In Part 2, we focus on the radiologic appearance of common noncardiac sources of chest pain, including gastrointestinal, pulmonary, and musculoskeletal etiologies.

Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision.

BACKGROUND: Slipped rib syndrome (SRS) is a painful disorder caused when 1 or more of the 8th-10th false ribs become abnormally mobile. Established treatment modalities include analgesia, intercostal nerve injection, and costal cartilage excision. No definitive surgical correction of SRS without cartilage excision has been previously described. We aimed to determine whether a nonexcisional repair technique in affected adults could demonstrate significant relief from SRS using standardized outcome measures. METHODS: We performed a retrospective review of cases of SRS treated at our institution in 2019. We obtained data by survey before and after sutured 10th rib fixation, using a self-reported rating scale from 0-10 at defined intervals. Surveyed outcome measures were compared pre- and postoperatively using the Wilcoxon signed rank sum test. The use of neural modulating, narcotic, and nonsteroidal antiinflammatory drug medications was also compared pre- and postoperatively using McNemar's test where applicable. RESULTS: SRS was diagnosed using clinical examination alone in 42 adults and repaired in 29 patients. Median postoperative improvement in pain at 1 and 6 months was 75% (P < .001) and 80% (P < .001), respectively. Improvements in other outcome measures were similar. In patients who took pain medications preoperatively, narcotics were discontinued at 1 month by 100%, neural modulators by 86%, and nonsteroidal antiinflammatory drugs by 92% (all P values < .001). Pain medication use remained minimal at 6 months in 23 (79%) of patients completing follow-up. CONCLUSIONS: Minimally invasive slipped rib repair in adults provides significant relief of SRS, offering a useful alternative to costal cartilage excision. It is well tolerated and effective.

A Comprehensive Review of Slipping Rib Syndrome: Treatment and Management.

Purpose of Review: This is a comprehensive review and update on advances in the understanding and treatment of slipping rib syndrome. It covers the physiology and pathophysiology at the basis of the syndrome, epidemiology and clinical presentation as well as diagnosis. It goes on to review the available literature to provide description and comparison of the available methods for alleviation. Recent Findings: Slipping rib syndrome stems from irritation of intercostal nerves. It is caused by slipping of the costal cartilage and the resulting displacement of a false rib and pinning underneath the adjacent superior rib and nerve irritation. It is rare and spans genders and ages; most evidence about epidemiology is conflicting and mostly anecdotal. Risk factors include trauma and high intensity athletic activity. Presentation is of a sudden onset of pain with jerking motion; the pain can be localized, radiating or diffuse visceral. It is often alleviated by positions that offload the impinged nerve. Diagnosis is clinical, and can be aided by Hooking maneuver and dynamic ultrasound. Definitive diagnosis is with pain relief on nerve block, visualization of altered anatomy during surgery and relief after surgical correction. Initial treatment includes rest, ice and NSAIDs, as well as screening for co-morbid conditions, as well as local symptomatic relief. Injection therapy with local anesthetics and steroids can provide a diagnosis as well as symptomatic relief. Surgical correction remains the definitive treatment. Summary: Slipping rib syndrome is a rare cause of chest pain that could be perceived as local or diffuse pain. Diagnosis is initially clinical and can be confirmed with nerve blocks and surgical visualization. Initial treatment is symptomatic and anti-inflammatory, and definitive treatment remains surgical. More recently, advanced surgical options have paved way for cure for previously hard to treat patients.

A case of Tietze's syndrome visualized on PET/CT-FDG.

We report an interesting image of a 49-year-old woman revealed with Tietze's syndrome (TS) by ¹8F-FDG PET/CT. She presented with right upper sternum pain with a hard and fixed palpable mass. Chest radiograph and CT-Scanner revealed no abnormalities. PET/CT-FDG showed a hypermetabolic activity around right sternoclavicular joint, which was the correct symptomatic lesion. Hence, FDG PET/CT may be useful for diagnosing TS and to accurately detect the symptomatic lesion.

Immunopathological findings in a cat with auricular chondritis.

At clinical examination, a 5-year-old male domestic short-haired cat exhibited painful swelling and erythema of the pinnae of both ears. Microscopically, the lesions on both pinnae were composed of diffuse granulomatous chondritis with degeneration and necrosis of the pinnal cartilage. Numerous mast cells were also observed within and surrounding the inflammatory lesion. Immunohistochemistry showed a mixed inflammatory infiltrate characterised by the predominance of macrophages (CD68+, MAC 387+ and Lysozyme+), T lymphocytes (CD3+), some B lymphocytes (CD79α+) and neutrophils. Immunopathological characterisation of the lesion showed a granulomatous inflammation profile and suggests that the morphological changes and immunopathogenesis of auricular chondritis in cats presents a similarity with relapsing polychondritis in humans.

Primary infectious costochondritis due to Prevotella nigrescens in an immunocompetent patient: clinical and imaging findings.

Infection of costal cartilage is a rare observation. We report the case of a 43-year-old male patient without relevant history who presented with a progressive painful swelling of the left chest wall since 4 months. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated an abscess within the left ninth costal cartilage with surrounding reactive changes. A CT-guided biopsy was performed and the culture of the sample revealed the presence of Prevotella nigrescens. Musculoskeletal infections by Prevotella are rarely described in the literature, Prevotella oralis and Prevotella bivia being the most frequently observed pathogens. These infections usually originate from a hematogenous spread after thoracic surgery or dental procedure. In our patient, conservative treatment was chosen. A clinical improvement was noted after 1-month antibiotherapy, confirmed by short-term and 6-month imaging follow-up showing the complete disappearance of all previously observed abnormalities.

Ultrasound-Guided Corticosteroid Injection in a Patient With Tietze Syndrome Combined With Costochondral Joint Swelling.

Tietze syndrome is an uncommon disease of unknown etiology that manifests as pain and tenderness of the parasternal joints. To date, however, there has been no report on ultrasonographic findings concerning swelling of the costochondral joint in Tietze syndrome. Moreover, there has been no research investigating images of ultrasound-guided corticosteroid injection, although corticosteroid injection is one of the most important treatments for Tietze syndrome. Therefore, we report a case of Tietze syndrome where ultrasound images were used in the diagnostic and therapeutic process. A 70-yr-old man was seen for left chest pain that had lasted for several weeks. Physical examination at our clinic revealed a focal tenderness of the left third costochondral joint, and an ultrasound showed a swelling of the left third costochondral joint. Considering both the radiological and the clinical examination, the patient received a diagnosis of Tietze syndrome with costochondral joint swelling. Then, the patient agreed to an ultrasound-guided left third costochondral corticosteroid injection after receiving a detailed explanation of the disease and treatment. After receiving three ultrasound-guided corticosteroid injections, his chest pain subsided, and the swelling and tenderness also disappeared completely. Collectively, our case suggests that ultrasound is important in the diagnosis and treatment of Tietze syndrome.

Diagnostic value of fluorine-18 deoxyglucose positron emission tomography/computed tomography in deep sternal wound infection.

OBJECTIVES: Deep sternal wound infection (DSWI) is a refractory complication after heart surgery, and debridement is the first-line treatment. The accurate identification of the extent of the infection is the key to successful debridement. The present study assessed the diagnostic accuracy of fluorine-18 deoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) for identifying the infected area of DSWI. METHODS: Between February 2015 and May 2017, 73 consecutive patients with suspected DSWI received 18F-FDG PET/CT examinations before their operation. The PET/CT and extracted CT images were analyzed by nuclear medicine physicians and radiologists to determine whether the sternum, mediastinum, vascular prosthesis, and each costal cartilage were infected. All the patients received debridement and chest wall reconstruction within 1 week following the PET scan. The final diagnosis was on the basis of surgical, microbiological, and histopathological findings. RESULTS: Of the 73 patients, 64, 54, 28, and 6 patients were diagnosed with sternal osteomyelitis, mediastinitis, costal chondritis, and vascular graft infection (VGI), respectively. The sensitivities of PET/CT for diagnosing sternal osteomyelitis, mediastinitis, and costal chondritis were 98.4%, 77.8%, and 100.0%, respectively, and the corresponding specificities were 94.7%, 82.1%, and 100.0%, respectively. PET/CT correctly diagnosed all six cases of VGI. There were 65 infected costal cartilages in the patients with costal chondritis. The sensitivity, specificity, and accuracy of PET/CT for locating infected costal cartilages were 81.5%, 99.8%, and 98.6%, respectively. CONCLUSIONS: PET/CT proved to be a useful tool for determining the depth of DSWI and for locating infected costal cartilage; therefore, this tool can help guide debridement.

Chest Pain: If It Is Not the Heart, What Is It?

Noncardiac chest pain is an angina-type discomfort without indication of ischemia. Diagnosis can be difficult because of its heterogeneous nature. Classification varies by specialty; gastroenterology uses the terminology gastroesophageal reflux disease related versus non-gastroesophageal reflux disease related. Other disciplines recognize noncardiac chest pain etiologies as having gastrointestinal, musculoskeletal, psychiatric, or pulmonary/other as underlying etiologies. Diagnostics yield a specific cause for effective treatment, which is aimed at the underlying etiology, but it is not always possible. Some patients with noncardiac chest pain have comorbidities and ongoing pain that lead to decreased quality of life and continued health care use.