Tietze's Syndrome: A Case Report

Abstract

In 1921 Tietze reported four cases of a syndrome of unknown etiology characterized by the appearance of painful swelling in the area of the upper chest cartilages. The clinical course is prolonged, benign, and usually only moderately painful, although at times incapacitating from severe pain. Since Tietze’s original description approximately 159 cases have been reported in the world literature and, of these, only 24 have been submitted to biopsy. Although relatively few cases have been reported, many patients with acute chest pain due to this syndrome may go unrecognized and thus the problem may not be so rare. The following is a case report which required surgery, and another histopathological specimen has become available. A 33 year old white married woman was admitted to St. Vincent’s Hospital on September 15, 1957 because of severe right anterior chest pain of 12 hours duration. She had been well until September 6, 1957 when she had an acute episode of malaise and temperature to 103#{176} F. Within 24 hours the fever subsided not to return, but dull pain in the right thorax and right shoulder developed, exacerbated by respirations and motion. Repeat physical examinations and chest fluoroscopy as well as a gall bladder series were unrevealing. Some relief was afforded with ‘meprolone’-2 administered four times daily for four days, but on September 12, 1957, six days after the onset of the illness, the pain became exquisite. The pain now was localized to the area over the right third costal cartilage and a discernible swelling was present at the same site. Physical examination was unremarkable except for a warm, extremely painful swelling over the right third costal cartilage. Laboratory data: white blood cells 8,200 normal differential, hemoglobin 14.3 grams per cent, sed rate 14 mm/hour, C reactive protein negative, total protein 6.8 grams per cent, albumin 5 grams per cent, globulin 1.8 grams per cent, alkaline phosphatase 4 Bodansky units, blood urea nitrogen 9, fasting blood sugar 80. X-ray film examination of chest, ribs, thoracic spine and skull were entirely normal. Electrocardiogram was normal. She remained afebrile in the hospital though in extreme pain. No benefit was noted from prednisone, 60 mgm. a day, for five days. Some relief was obtained with repeated intercostal xylocaine nerve blocks. Observation was continued at home. She received narcotics and a one week course of ‘butizolidin’ 400 mgms. daily without improvement. On October 26 the swollen area became more painful with associated ecchymoses of the skin. Although the clinical picture was consistent with Tietze’s syndrome, she was rehospitalized for surgical resection of the involved cartilage because of the protracted incapacitating pain. At surgery incision revealed subcutaneous edema and ecchymoses of the tissues in the area. The pectoral muscle was edematous. The third right costal cartilage was found to be buckled forward at an acute angle *Fnom the Medical and Surgical Services, St. Vincent’s Hospital.