Tietze's Syndrome Research Articles

The nonrandom occurrence of visits to the emergency department

Study objectives: We determine whether variation in the frequency of emergency department (ED) visits is beyond what would be expected by chance after adjusting for known confounders such as calendar and weather variables. Methods: The Poisson goodness-of-fit test was used to determine whether emergency visits in a Midwestern teaching hospital occurred randomly over time. Total visits, as well as selected diagnoses, were analyzed. Final diagnosis was determined using the physicians' final chart diagnosis, which was assigned an <i>International Classification of Diseases, Ninth Revision</i> code by one of the investigators. Data on appendicitis were obtained for 6 years to check for randomness of distribution; only cases of operatively confirmed appendicitis were included in the analysis. We also looked at the distribution of specific diagnoses that might be expected to occur randomly (eg, atrial fibrillation, urinary retention, headache). Multivariable Poisson regression was used to control for calendar and weather variables. Autocorrelation coefficients were used to detect "contagion" from one period to the next. Results: There were 24,100 ED visits in 1998, with 2,054 distinct final diagnoses. Forty-six visits were laboratory tests only, and 5 records were lacking a final diagnosis. The most common diagnoses were "abdominal pain" (643 visits), upper respiratory infection (548 visits), and open wound of finger (544 visits). Overall, visits did not occur randomly, even after controlling for time of day, day of week, academic calendar, season, and weather variables (<i>P</i><.001). Visits were more common on Sundays, in the fall, and on warm days. Of 32 diagnoses we predicted would occur randomly (eg, have a Poisson distribution), 29 did so, including appendicitis, congestive heart failure, chest pain, venous thrombosis, reflux esophagitis, intestinal obstruction, gastrointestinal foreign body, gastrointestinal hemorrhage, hypertension, right-lower-quadrant abdominal pain, subarachnoid hemorrhage, transient ischemic attack, atrial fibrillation, angina, cerebral hemorrhage, constipation, seizure, intermediate coronary syndrome, dizziness, hematuria, kidney stone, migraine, acute pancreatitis, rectal hemorrhage, blood in stool, syncope, tension headache, Tietze syndrome, and urticaria. The other 3, cerebrovascular accident, migraine headache, and back pain, were not randomly distributed. Conclusion: ED visits did not occur randomly over time. Most diagnoses that would be expected to occur randomly did so, but a few exhibited nonrandom variation. ED staff should be alert to nonrandom occurrence of disease as a mechanism for finding unsuspected causes or associations of different diseases.

Musculoskeletal problems of the chest wall in athletes.

Chest pain in the athlete has a wide differential diagnosis. Pain may originate from structures within the thorax, such as the heart, lungs or oesophagus. However, musculoskeletal causes of chest pain must be considered. The aim of this review is to help the clinician to diagnose chest wall pain in athletes by identifying the possible causes, as reported in the literature. Musculoskeletal problems of the chest wall can occur in the ribs, sternum, articulations or myofascial structures. The cause is usually evident in the case of direct trauma. Additionally, athletes' bodies may be subjected to sudden large indirect forces or overuse, and stress fractures of the ribs caused by sporting activity have been extensively reported. These have been associated with golf, rowing and baseball pitching in particular. Stress fractures of the sternum reported in wrestlers cause pain and tenderness of the sternum, as expected. Diagnosis is by bone scan and limitation of activity usually allows healing to occur. The slipping rib syndrome causes intermittent costal margin pain related to posture or movement, and may be diagnosed by the 'hooking manoeuvre', which reproduces pain and sometimes a click. If reassurance and postural advice fail, good results are possible with resection of the mobile rib. The painful xiphoid syndrome is a rare condition that causes pain and tenderness of the xiphoid and is self-limiting. Costochondritis is a self-limiting condition of unknown aetiology that typically presents with pain around the second to fifth costochondral joints. It can be differentiated from Tietze's syndrome in which there is swelling and pain of the articulation. Both conditions eventually settle spontaneously although a corticosteroid injection may be useful in particularly troublesome cases. The intercostal muscles may be injured causing tenderness between the ribs. Other conditions that should be considered include epidemic myalgia, precordial catch syndrome and referred pain from the thoracic spine.

A variant of Tietze's syndrome occurring after reconstructive breast surgery.

Costosternal chondrodynia (Tietze's syndrome variant) should be considered in those rare patients who present with severe breast pain several months after reconstructive breast surgery. The authors treated 25 cases, 3 of which are discussed in detail, where the origin of the pain was traced to the costosternal cartilages. The differential diagnosis and management of this hitherto undescribed problem after breast surgery are discussed.

Stellate ganglion block therapy for a patient with Tietze's syndrome.

Stellate ganglion block therapy for a patient with Tietze's syndrome.

Ultrasonographic assessment of local steroid injection in Tietze's syndrome

The purpose of this study was to investigate the value of ultrasonographic examination in the diagnosis of Tietze's syndrome and assessment of the changes in costal cartilage following local steroid injection. Nine patients with Tietze's syndrome and 20 normal subjects were studied consecutively. Ultrasound examination was performed using a Sonoline SL Siemens Machine with a linear 5 MHz small parts transducer and ATL Apogee 800 with a 10 MHz linear array transducer. The affected costochondral joint was injected with a combination of 15 mg of triamcinolone hexacetonide and 1 ml of 2% lidocaine. Ultrasound examination was performed following the clinical evaluation and repeated immediately after the injection, then 1 and 4 weeks later. Abnormal echo appearance was detected as an inhomogeneous increase in the echogenicity with intense broad posterior acoustic shadow. Hypoechogenicity and a decrease in the size of costal cartilage were observed 1 week after local steroid injection with absence of the posterior acoustic shadowing. Ultrasonographic examination of costal cartilage is easy and quick to perform. We believe that ultrasound should be the screening procedure of choice for Tietze's syndrome. Local steroid injection proved to be clinically safe and effective in the treatment of patients with Tietze's syndrome.

Sonography of the costal cartilage: Normal anatomy and preliminary clinical application

Costal cartilages of 10 controls and 12 patients with Tietze's syndrome (n = 6), deformed (exaggerated bowing) cartilage (n = 4), focal enlargement (n = 1), and cancer-invaded cartilage (n = 1) were examined with ultrasonography. In controls, ultrasonography detected 237 of 240 costal cartilages (98.8%) and 58 of 105 intercartilage connections (55%) with three variations. Correlation with CT was available in 7 patients (1 Tietze's syndrome, 4 deformities, 1 cartilage enlargement, and 1 cancer) among 8 patients whose CT results were known to the sonographer. Sonography showed normal (n = 4) or marginally blurred (n = 2) cartilages in 6 Tietze's syndromes. Ultrasonography is a promising technique in the examination of costal cartilages.

Echographic study of Tietze's syndrome

An echographic study of Tietze's syndrome was carried out. Three patients with clinical evidence of Tietze's syndrome were examined. Ten normal volunteers were studied as controls. In Tietze's syndrome a dishomogeneous increase of the echogenicity in pathological cartilage and an increased thickness vs. the opposite normal side were observed. A moderate thickness and a decreased echogenicity of surrounding soft tissues was observed in one case.

Sternocostal Joint Swelling–Clinical Tietze's Syndrome

Sixteen patients with painful tender swelling in the region of the sternocostal joint (SCJ) are reported and analysed against the background of a review of 106 previously reported patients with Tietze's syndrome. Seven patients fulfilled all the diagnostic criteria for Tietze's syndrome. The radiographic findings and/or the history of these patients suggested that local strain generated by respiration is a pathogenetic factor. Nine patients had a systemic arthritic disorder, skin disease, or psoriasis in their family. They differed from the 7 patients with local involvement and from those reviewed, by the rather frequent bilateral involvement, a frequent affection of the first SCJ and the manubriosternal joint, and a female predominance. Their SCJ swellings may be viewed as part of a seronegative arthritis.

Chest pain: a rheumatologist's perspective.

Chest pain is a frequent patient complaint that requires a careful history and physical examination to determine its cause. Cardiac and esophageal causes of chest pain are common, but musculoskeletal disorders such as Tietze's syndrome, chest wall pain syndromes, fibrositis, inflammatory arthritic conditions, cervical osteoarthritis, and disease of the thoracic spine may also result in chest pain. Musculoskeletal diseases must be differentiated from other causes of chest pain, since specific treatment of these rheumatic conditions often produces good results.

Radiographic findings in patients with clinical Tietze syndrome.

Thirteen patients with similar painful tender swelling in the region of the sternocostal joint (SCJ) are reported. X-ray tomography revealed changes which might explain the swelling in 11 patients. Three patients had anatomical variants of the sternum. One of these and a further two patients had marginal osteophytes at the affected SCJ, as signs of osteoarthrosis. Six patients with psoriasis, pustulosis palmoplantaris, or psoriasis in the family had past or present arthritis of the involved SCJ or the manubriosternal joint. Tomography was found to be a useful confirmatory examination in patients with clinical Tietze syndrome.

Reliability of computed tomography in the initial diagnosis and follow-up evaluation of Tietze's syndrome: Case report with review of the literature

The clinical entity of Tietze's syndrome is well known. It is benign in nature, self-limiting, and of unknown etiology. Computed tomography has proved most helpful in the initial evaluation of this disorder, especially as roentgenographic plain films have been essentially noncontributory in the past. A case of this disorder was followed up over the course of 2 months, and the clinical and computed tomography findings were correlated. The authors believe that computed tomography is the most exact and reliable modality for the follow-up evaluation of patients with Tietze's syndrome.

CLINICAL EXPERIENCE OF DRUG TREATMENTS FOR MASTALGIA

Results of randomised trials and open studies in 291 patients with severe persistent breast pain in whom breast cancer had been excluded showed that drug therapy produced a good or useful result in 77% of those with cyclical mastalgia and 44% of those with non-cyclical mastalgia. In patients with cyclical mastalgia good or useful responses were obtained with danazol in 70%, with bromocriptine in 47%, and with evening-primrose oil in 45%. The equivalent response rates in patients with non-cyclical mastalgia were 31%, 20%, and 27% respectively. Progestagens were not effective in either group. Failure to respond to one drug did not preclude response to a different drug. Patients with Tietze's syndrome did not respond to drug therapy, but 7 out of 10 responded to injection of lignocaine and hydrocortisone around the affected costochondral junction.

CT Observation of Rib Abnormalities

The CT studies in 63 patients in which rib abnormality was identified or excluded were retrospectively analyzed. The CT features were detailed and correlated with other available radiographic findings as well as clinical data. Contiguous spread of tumor to rib or metastasis to rib characteristically showed subtle or complete segmental lytic rib destruction. An accompanying extrapleural soft tissue mass was frequently seen with metastatic disease and myeloma. In nine patients CT showed rib destruction that had been obscured on chest radiography by heart, diaphragm, mass, or pleural effusion. Other imaging studies prompted consideration of neoplasm in seven patients in whom CT clearly showed benign post-traumatic or developmental lesions. Six patients had a clinically suspected chest wall mass excluded, leading to the diagnosis of Tietze syndrome. The ribs should be carefully inspected on all CT studies of the thorax and upper abdomen. Computed tomography is helpful when other imaging techniques, such as rib films or isotopic bone scans, have not resolved the question of clinically or radiographically suspected rib abnormality.

Computed tomography of Tietze syndrome.

Six patients with clinical features suggestive of Tietze syndrome had a thoracic computed tomographic (CT) examination following a normal plain film or tomographic examination (or both) of the affected costochondral junction. A chest wall mass was excluded in all six patients. The CT findings included enlargement of the costal cartilage at the site of complaint (two patients), ventral angulation of the involved costal cartilage (two patients), and normal anatomy of the costochondral junction (two patients). Exclusion of a chest wall mass by CT may obviate the need for operative intervention.

Pain in Xiphisternal Joint

To the Editor.— In the letter on Tietze's syndrome by Carl Jelenko III, MD (242:2556, 1979), he claims he described the first reported cases of Tietze's syndrome affecting the xiphisternal joint in 1974. Current Therapy , 1967 (Philadelphia, WB Saunders Co), page 108 has an article, Rib Syndrome, by M. S. Rawlings, MD, which seems to describe the same syndrome, with appropriate therapy. Curiously, neither Jelenko's letter nor the article by Epstein et al (241:2793, 1979) cite Current Therapy as a reference.

Classification of Anterior Chest Wall Syndromes

To the Editor.— We wish to congratulate Espstein and coauthors (241:2793, 1979) for their excellent contribution on chest wall syndrome as a common cause of unexplained cardiac pain. It is clear from the description of their 12 patients that all had the anterior chest wall syndrome, more popularly known as costochondritis. The terms "Tietze's syndrome" and "costochondritis" are often used interchangeably. While both disorders are characterized by inflammation of one or more costal cartilages, Tietze's syndrome is associated with local swelling while costochondritis is not. Consequently, Tietze's syndrome is easier to recognize but unfortunately is far less common than costochondritis. In this regard, the two letters to the editor (242:2556, 1979; 242:2394, 1979) suggesting that the patients of Epstein et al had Tietze's syndrome are inappropriate. The cause of Tietze's syndrome is unknown, although minor or obscure trauma (coughing, for example) may be operative. The syndrome occurs in all age

Tietze's Disease Predates 'Chest Wall Syndrome'

<h3>To the Editor.—</h3> The article "Chest Wall Syndrome: A Common Cause of Unexplained Cardiac Pain" by Epstein et al (241:2793, 1979) describes a symptom-sign complex in which neuromusculoskeletal derangements mimic cardiac disease. That the patient group was at a specialized tertiary care center may have contributed to the highly sophisticated, extensive, costly and (in the cases of the 12 patients described) perhaps unnecessary diagnostic evaluations the authors detailed. However, I was greatly interested in the article because of its neglect of an entity probably more commonly experienced in real-world community practice: peristernal perichondritis (Tietze's syndrome¹). In 1974, I described the first reported cases of Tietze's syndrome affecting the xiphisternal joint²and, in 1977, analyzed 24 cases of xiphisternal perichondritis.³The disease has protean manifestations and is a mimic of severe cardiac, pulmonary, intra-abdominal, and other diseases. Among our patients, who ranged in age from 18 to 72

Perichondritis (Tietze's syndrome) at the xiphisternal joint: A mimic of severe disease

Tietze's syndrome (peristernal chondritis or perichondritis) is a self-limited, painful inflammatory condition of the costochondral, sternoclavicular, manubriosternal or xiphisternal junctions. It is benign, and affects all ages, sexes and races equally. The principal manifestations are pain and, frequently, a mass most commonly at the costochondral junctions. In 1974, C.J. described the first cases to be reported at the xiphisternal junction. We describe here 24 cases at that site. These patients' presenting symptoms suggested cardiac, pulmonary, intraabdominal and other severe disease processes. Diagnosis was made on clinical grounds based on a high index of suspicion. Treatment comprised infiltration of local anesthetic to the afflicted joints with prompt, complete and prolonged relief in 21 (87.5%) of the cases, and complete temporary relief in three (12.5%). We suggest that a possible mechanism for the referral of pain is the relationship of the xiphisternal joint to a variety of structures including autonomic nerves that accompany the internal mammary arteries.

Epidemic of Tietze's syndrome.

Epidemic of Tietze's syndrome.

ORTHOPEDIC SYMPTOMS IN PUSTULAR BACTERID (PUSTULOSIS PALMARIS ET PLANTARIS): TIETZE'S SYNDROME AND ARTHRITIS OF MANUBRIOSTERNAL JOINT DUE TO FOCAL INFECTION

Painful orthopedic symptoms in the sternal area, such as arthritis of the manubriosternal and sternoclavicular joint or Tietze's syndrome, were found in 14 of 132 cases of pustulosis palmaris et plantaris. The majority of the pustulosis palmaris et plantaris patients with orthopedic symptoms had skin eruptions not only on the palms and soles, but also on the backs of the hands and feet, the arms, the legs and the trunk. Such cases were usually accompanied by elevation of the erythrocyte sedimentation rate, leucocytosis, changes in serum globulin, and also pyrexia at the time of exacerbation. The skin and orthopedic symptoms often worsened after acute exacerbation of the focal infection, and occasionally responded to tonsillectomy or chemotherapy with antibiotics, which is suggestive of the probable cause of the bacterid.