Chest Pain- Volleyball

Abstract

HISTORY: A 20-year-old female collegiate volleyball player presented with a 3-month history of chest pain. Pain was non-exertional, localized to the mid-chest and described as constant with rating of 8/10. She initially sought consult 3 months prior in the emergency room with EKG and labs unremarkable. The patient was diagnosed with costochondritis and managed with a steroid dose pack that provided temporary relief. Her pain then progressively increased to inability to tolerate volleyball activity. Of note, she reported mild left hip and lower back pain that started one week prior to consult. PHYSICAL EXAMINATION: Cardiac exam revealed regular rate and rhythm with no murmurs. Tenderness to palpation was significant over the sternomanubrial junction. Left hip exam revealed positive piriformis test and sacroiliac compression test. Range of motion was full throughout the bilateral upper and lower extremities. Strength, reflexes, sensation, and pulses normal throughout. DIFFERENTIAL DIAGNOSIS: 1. Costochondritis 2. Osteomyelitis of sternum 3. Seronegative spondyloarthropathy TEST AND RESULTS: Anterior-posterior and lateral chest x-rays: —Normal cardiac silhouette. No bony abnormalities. Anterior-posterior and lateral pelvis x-rays: — Normal joint space. No bony deformities. Nuclear medicine total bone scan: — Increased uptake at sternomanubrial interval concerning for inflammatory process. Further evaluation with CT scan suggested. CT scan of the sternum with IV contrast: — Increased uptake at the manubriosternal joint demonstrating subchondral sclerosis. CBC, RF, ESR, CRP, HLA-B27, ANA, Lupus panel and Lyme titers ordered. — Lab results normal with the exception of slightly elevated ESR. FINAL/WORKING DIAGNOSIS: Seronegative spondyloarthropathy TREATMENT AND OUTCOMES: 1. Patient referred to Rheumatology given concern for inflammatory arthritis. 2. Initiated NSAIDs and physical therapy for suspected piriformis syndrome. 3. MRI of bilateral SI joints performed and suggestive of sacroiliitis. 4. In preparation for TNF agent treatment, patient found to be Hep B core antibody positive and referred to Hepatology. 5. Started entacavir for Hepatitis B treatment and adalimumab. 6. After 2 months, the patient returned to full volleyball participation with complete resolution of her symptoms.