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Costochondritis, Pediatric

Basics

Description

- Infectious - Bacterial - Staphylococcus aureus (especially after thoracic surgery) - Salmonella (in sickle cell disease) - Escherichia coli - Pseudomonas sp. - Klebsiella sp.

- Fungal - Aspergillus flavus - Candida albicans

- Inflammatory costochondritis - Pain usually preceded by exercise or an upper respiratory tract infection - Description of pain - Usually sharp - Affects the anterior chest wall - Localized or radiates to the back or abdomen - Usually unilateral (left side greater than right side)

- Tietze syndrome - Onset is usually abrupt but can be gradual. - Believed to be caused by a minor trauma, although etiology is unknown - Description of pain - Radiates to arms or shoulder - May last up to several weeks - Swelling at the sternochondral junction may persist for several months to years.

- Radiologic studies (chest x-ray, CT) usually not helpful - Gallium scan - May be useful in some cases of infectious origin - Not highly specific - May show increased radionuclide uptake - No evidence of osteomyelitis of the sternum in most cases

- GI - Gastroesophageal reflux - Esophagitis - Gastritis - Achalasia

- Mechanical - Muscle strain - Stress fractures - Precordial catch syndrome - Trauma

- Rheumatologic - Rheumatoid arthritis - Ankylosing spondylitis

- Oncologic - Rhabdomyosarcoma - Leukemia - Ewing sarcoma

- Miscellaneous - Tietze syndrome - Psychogenic chest pain - Breast tissue pain (both sexes)

- Inflammatory costochondritis - Anti-inflammatory and analgesic agents - Reassurance - If pain disturbs normal activities and sports, infiltration with local anesthetic may prove useful.

- Infectious costochondritis - Prolonged course of intravenous (IV) antibiotics - Prompt surgical resection of all involved cartilage - Reconstructive surgery with muscular flaps should be done.

- Inflammatory costochondritis - Important cause of school absence - Adolescents tend to limit physical activity unnecessarily for long periods. - Restriction of activities is usually not required. - Most adolescents still worry about cardiac problems, even after the diagnosis has been made.

Costochondritis is chest pain that emanates from a costal cartilage and is reproducible on compression of that cartilage.

Epidemiology

  • Frequency of sternal wound infections following median sternotomy is 0.1-1.6%.
  • Costochondritis accounts for 10-31% of all pediatric chest pain.
  • Peak age for chest pain in children is 12-14 years.

Pathophysiology

  • Inflammation of unknown etiology (histologic examination is usually normal)
  • InfectionCan present months to years after surgery (the costal cartilage is avascular, making it vulnerable to infection if it has been exposed, injured, or denuded of perichondrium)Complication of median sternotomyOccurs by spread from adjacent osteomyelitis or may arise de novo during surgery

Etiology

  • InfectiousBacterialStaphylococcus aureus (especially after thoracic surgery)Salmonella (in sickle cell disease)Escherichia coliPseudomonas sp.Klebsiella sp.FungalAspergillus flavusCandida albicans
  • Posttraumatic injury

Diagnosis

History

  • Inflammatory costochondritisPain usually preceded by exercise or an upper respiratory tract infectionDescription of painUsually sharpAffects the anterior chest wallLocalized or radiates to the back or abdomenUsually unilateral (left side greater than right side)The 4th-6th costochondral junction is the usual site of pain.Motion of the arm and shoulder on the affected side elicits the pain.Girls are affected more often than are boys.
  • Tietze syndromeOnset is usually abrupt but can be gradual.Believed to be caused by a minor trauma, although etiology is unknownDescription of painRadiates to arms or shoulderMay last up to several weeksSwelling at the sternochondral junction may persist for several months to years.Usually affects the 2nd or 3rd costochondral jointPain is aggravated by sneezing, coughing, deep inspiration, or twisting motions of the chest.No differences in frequency between sexes
  • Infectious costochondritisSlow, insidious courseUsually unimpressive clinical symptomatology

Physical Exam

  • Usually normal
  • Inspect for evidence of trauma, scars, bruising, and swelling.
  • Palpation and percussion of the costochondral and costosternal junctions should reproduce and localize the pain.
  • In Tietze syndrome, spindle-shaped swelling is visible at the sternochondral junction.

Diagnostic Tests & Interpretation

Lab

  • WBC count not helpful (even when infection present)
  • EKG (may be helpful if cardiac etiology is being considered)

Imaging

  • Radiologic studies (chest x-ray, CT) usually not helpful
  • Gallium scanMay be useful in some cases of infectious originNot highly specificMay show increased radionuclide uptakeNo evidence of osteomyelitis of the sternum in most cases
  • Technetium bone scan

Differential Diagnosis

  • CardiovascularMyocardial infarctionPericarditisPericardial effusionMyocarditisEndocarditisCardiomyopathyPremature ventricular contractionsSupraventricular tachycardiaDissecting aneurysm
  • PulmonaryAsthmaExercise-induced bronchospasmPneumoniaPleural effusionPneumothoraxPulmonary embolism
  • GIGastroesophageal refluxEsophagitisGastritisAchalasia
  • MechanicalMuscle strainStress fracturesPrecordial catch syndromeTrauma
  • RheumatologicRheumatoid arthritisAnkylosing spondylitis
  • OncologicRhabdomyosarcomaLeukemiaEwing sarcoma
  • MiscellaneousTietze syndromePsychogenic chest painBreast tissue pain (both sexes)

Treatment

General Measures

  • Inflammatory costochondritisAnti-inflammatory and analgesic agentsReassuranceIf pain disturbs normal activities and sports, infiltration with local anesthetic may prove useful.
  • Infectious costochondritisProlonged course of intravenous (IV) antibioticsPrompt surgical resection of all involved cartilageReconstructive surgery with muscular flaps should be done.

Alert

  • Infectious costochondritisLong-term IV antibiotics alone do not resolve the problem; surgical resection and repair also are required.There is a tendency for the infection to spread to adjacent costal cartilages and across the sternum to the contralateral chest wall.In general, avoid costochondral junctions when performing surgical procedures in the chest (i.e., chest tube placement).

Alert

  • Inflammatory costochondritisImportant cause of school absenceAdolescents tend to limit physical activity unnecessarily for long periods.Restriction of activities is usually not required.Most adolescents still worry about cardiac problems, even after the diagnosis has been made.

Ongoing Care

Follow-up Recommendations

Patient Monitoring

  • Inflammatory costochondritisLong-lasting conditionFollow-up once a year is recommended.
  • Infectious costochondritisLong-term follow-up after surgery is mandatory.

Prognosis

  • Inflammatory costochondritis: excellent
  • Infectious costochondritis: prognosis relates toUnderlying clinical condition of the patient (i.e., immunocompromised, postradiation therapy for cancer, postcardiac surgery)Extent of surgery required to reconstruct the area damaged by the infection

Additional Reading

  • Brown RT, Jamil K. Costochondritis in adolescents. A follow-up study. Clin Pediatr. 1993;32(8):499-500. [View Abstract]
  • Kocis KC. Chest pain in pediatrics. Pediatr Clin North Am. 1999;46(2):189-203. [View Abstract]
  • Mendelson G, Mendelson H, Horowitz SF, et al. Can (99m)technetium methylene diphosphate bone scans objectively document costochondritis? Chest. 1997;111(6):1600-1602. [View Abstract]
  • Selbst DM. Consultation with the specialist. Chest pain in children. Pediatr Rev. 1997;18(5):169-173. [View Abstract]
  • Son MB, Sundel RP. Musculoskeletal causes of pediatric chest pain. Pediatr Clin North Am. 2010;57(6):1385-1395. [View Abstract]
  • Talner NS, Carboni MP. Chest pain in the adolescent and young adult. Cardiol Rev. 2000;8(1):49-56. [View Abstract]

Codes

ICD09

ICD10

  • M94.0 Chondrocostal junction syndrome [Tietze]

SNOMED

  • 64109004 Costalchondritis (disorder)
  • 30128009 Tietze's disease

FAQ

  • Q: Am I having or will I have a heart attack?
  • A: Chest pain does not imply a heart problem. This pain arises from the chest wall; there is no risk of a myocardial infarction. A cardiac etiology to chest pain in an adolescent is usually uncommon.
  • Q: Is costochondritis related to arthritis?
  • A: There is no relation to any form of arthritis.
  • Q: Where does the name Tietze syndrome come from?
  • A: The syndrome is named after German surgeon Alexander Tietze (1864-1927), who first described the syndrome in 1921.