Chest Pain in a 54-Year-old Man

Abstract

A 54-year-old man was referred to the orthopaedic department for evaluation of pain in the left side of his chest. He complained of constant pain that radiated to the left hypochondrium and to the thoracic spine. Symptoms started insidiously 6 months earlier and became progressively worse. Symptoms subsided with the use of oral analgesics. There was no history of coughing, dyspnea, malaise, fatigue, fever, night sweating, or weight loss. There were no other clinical symptoms. Thirty years earlier he was diagnosed with multiple hereditary exostoses that affected primarily the hips, the knees, and the elbows. His father and grandfather were similarly affected. At the time of diagnosis he had surgical resection of exostoses arising in his knees to improve knee function. Fifteen years earlier, he had surgical resection of an exostosis in his right hip for similar reasons. In both cases, biopsies of the removed exostoses were negative for malignancy. The rest of his medical and surgical records were unremarkable. Physical examination revealed an apparently healthy man. There was no tenderness during percussion and palpation of the left chest and left hypochondrium. Percussion and palpation of the spine and paraspinal muscles in the thoracic region revealed no tenderness. Chest auscultation was normal. The range of motion of his spine was in normal limits. His neurologic examination was free of findings. All laboratory values, including erythrocyte sedimentation rate, C-reactive protein, and arterial blood gases were in normal limits. Radiographic investigations included plain radiographs (Fig 1), bone scans (Fig 2), computed tomography (CT) scans (Fig 3) and MRI scans (Fig 4). Based on the history, physical examination, laboratory findings and imaging studies, what is the differential diagnosis? From the *First Department of Orthopaedic Surgery, Athens University School of Medicine; and the †Department of Pathology, KAT Hospital, Athens, Greece. Each author certifies that he or she has no commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution has approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. Correspondence to: George S. Themistocleous, MD, DSc, Georgiou Theotoki 11 Street, 18538 Piraeus, Greece. Phone: 011302104517673; Fax: 011302104539826; E-mail: themistocleousgeorge@hotmail.com. DOI: 10.1097/01.blo.0000194315.79883.2b CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 444, pp. 261–268 © 2006 Lippincott Williams & Wilkins