Full text of DOI:10.1007/PL00011203

Clin Rheumatol (2001) 20:276–278
ß 2001 Clinical Rheumatology
Clinical
Rheumatology
Case Report
Malignant Tumor with Chest Wall Pain Mimicking Tietze’s Syndrome
T. Thongngarm, L. B. Lemos, N. Lawhon and V. Harisdangkul
University of Mississippi Medical Center, Jackson, Mississippi, USA
Abstract: Chest pain is commonly caused by muscu-
loskeletal chest wall disorders. Tietze’s syndrome is a
relatively rare cause of chest wall pain characterised by
non-suppurative, painful swelling of the upper costal
cartilages. The diagnosis should be based on these
classic clinical features after excluding other potential
causes of pain. A patient who was diagnosed with
Tietze’s syndrome but was found to have squamous cell
carcinoma of the mediastinum with unknown primary
site invading the sternum and anterior chest wall is
presented for discussion.
pain and swelling of the anterior chest wall resembling
Tietze’s syndrome. The differential diagnosis of chest
wall pain, including Tietze’s syndrome, is discussed.
Case Report
A 44-year-old African-American woman with a long
history of cigarette smoking presented with chest pain at
the level of the upper sternum and costochondral
junctions for 6 months. A chest X-ray, electrocardiogram
and exercise stress test showed no abnormality. The
patient was diagnosed as having Tietze’s syndrome and
treated with non-steroidal anti-inflammatory drugs
(NSAIDs) and intramuscular steroid injection. Six
months later she developed right shoulder pain with
stiffness, and continued to have increasing chest pain at
the sternomanubrial junction and right upper costochon-
dral joints. The character of the pain was dull, constant,
and worse at night. There was no pain in the hands or
any other joints. There was no history of fever, weight
loss, night sweats, cough, dysphagia, rash, alopecia or
Raynaud’s phenomenon. Antinuclear antibody (ANA)
was positive in a titre of 1:320, speckled pattern.
Erythrocyte sedimentation rate (ESR) was 87 mm/h.
Other blood tests, including complete blood count, blood
chemistry, anti-ds-DNA and urinalysis, were all within
normal limits. The patient was referred to the
rheumatology service for evaluation of costochondritis
and suspected connective tissue disease. Physical
examination was within acceptable limits except for
palpable tenderness and mild swelling of the anterior
chest wall at the sternomanubrial junction and right
upper costochondral joints. A chest X-ray was normal
with the exception of a soft tissue shadow in the right
paratracheal region. A chest CT scan showed a large,
superior mediastinal mass extending into the sternum
and anterior chest wall area with slightly enlarged lymph
Keywords: Anterior chest wall pain; Costochondritis;
Malignancy; Tietze’s syndrome
Introduction
Tietze’s syndrome, a relatively rare disorder compared
to general costochondritis, is characterised by painful
non-suppurative swelling of the cartilaginous articula-
tions of the anterior chest wall [1,2]. The diagnosis relies
on this classic clinical manifestation after the exclusion
of other conditions that affect costal cartilages, such as
infection, malignancy, relapsing polychondritis and
other inflammatory processes [3]. Mediastinal squamous
cell carcinoma of unknown origin presenting with
swelling of the costochondral joint is also extremely
rare [4,5]. We describe a case of mediastinal squamous
cell carcinoma of unknown primary site with metastasis
to the anterior chest wall. The patient presented with
Correspondence and offprint requests to: Dr Valee Harisdangkul,
Division of Rheumatology and Molecular Immunology, L525 Clinical
Sciences Building, University of Mississippi Medical Center, 2500
North State Street, Jackson, MS 39216, USA. Tel: 601-984-5540;
Fax: 601-984-5535; e-mail: Harisdangk@aol.com

Malignant Tumor with Chest Wall Pain Mimicking Tietze’s Syndrome
277
nodes at the right paratracheal region (Fig. 1A, 1B). The
lung parenchyma was clear, with no focal infiltrates or
atelectasis. Radiographic-guided fine-needle aspiration
(FNA) biopsy revealed squamous cell carcinoma (Fig.
2). Abdominal CT scans and pelvic examination with
pap smear failed to reveal a primary site. A diagnosis of
squamous cell carcinoma of unknown primary site was
made and treatment with systemic chemotherapy, VP-16
and cis-platinum for presumed non-small cell lung
cancer was instituted.
Discussion
Chest pain is a common symptom, with a diverse
differential diagnosis based upon anatomical regions and
clinical features [3,6–9] (Table 1). Costochondritis is the
most common disorder and accounts for 30% of all
patients with chest pain [9]. Despite their clinical
significance, musculoskeletal disorders receive little
attention and are often overlooked as causes of chest
pain.
Tietze’s syndrome was first described in 1921 by
Tietze. It is defined as a self-limiting disorder
characterised by non-suppurative painful swelling of
the upper costal cartilages of unknown etiology [1]. The
syndrome is usually differentiated from the costochon-
dritis that also produces pain and tenderness in the same
area but without swelling [6,9]. It occurs commonly in
individuals under the age of 40 [3], the incidence being
the same in both sexes [3]. The disorder has a
predilection for the second and third costochondral
junctions and occurs with the same frequency on both
sides of the chest [3,7]. The lesion is single and
unilateral in 70%–80% of cases [3,6]. The principal
presenting symptom is pain in the anterior chest wall of
variable intensity and either acute or insidious in onset
[3,6,7]. Pain may radiate to the shoulder and arm and is
aggravated by motion of the ribcage [3,6]. The diagnosis
is confirmed by palpation and the finding of tenderness
over swollen costal cartilages, but without warmth and
erythema [3]. Laboratory findings, including ESR and
Fig. 1. (a) CT scan of the chest showing lytic destruction of
manubrium and medial left clavicle (arrow head). Mass is seen
anteriorly and posteriorly (shaft arrow). (b) CT scan of the chest
showing more severe destruction of proximal sternum (arrow head)
with larger surrounding soft tissue mass (shaft arrow).
Table 1. Classification of chest wall pain
Local causes
Systemic causes
Costochondritis
Tietze’s syndrome
Rib trauma
Fibromyalgia
Psychogenic rheumatism
Osteoarthritis
Rheumatoid arthritis
Crystalline-induced arthritides
Seronegative spondyloarthropathy
Traumatic muscle pain
Benign overuse myalgia
Slipping rib syndrome
Sternoclavicular arthritis
Manubriosternal arthritis
Painful xiphoid syndrome
Precordial catch syndrome
Epidemic myalgia
Referred pain from:
cervical spine, shoulders,
intrathoracic visceral organs,
radiculopathy
Local infection, herpes zoster
Bony metastasis from surrounding
tumors, carcinoma of breast, lung,
thyroid, kidney or prostate
Fig. 2. Large group of malignant cells densely grouped, showing
moderate pleomorphism, dense chromatin and few small nucleoli. The
insert demonstrates concentric arrangement of anucleated cells
forming a keratinised pearl.

278
T. Thongngarm et al.
radiographic examination, are usually normal [3,6,7].
Bone scanning is sensitive but not specific. Pinhole
scintigraphy has been reported to enhance diagnostic
specificity [10]. CT scan is the radiologic study of choice
to exclude other abnormalities of the sternum and its
articulations [11]. Differential diagnosis includes infec-
tion, malignancy, antecedent trauma, osteoarthritis and
inflammatory arthritides secondary to relapsing poly-
chondritis, rheumatoid arthritis, seronegative spondy-
loarthropathies, rheumatic fever and crystalline-induced
arthritides. Diagnosis is made by exclusion, with
correlation of history, physical examination and labora-
tory investigations [2,3,6,7]. Treatment includes reassur-
ance, local application of heat, mild analgesics and
NSAIDs. In refractory cases local injections of lidocaine
with steroids or intercostal nerve block are indicated
[3,6]. The clinical course varies from a few weeks to
several years. Spontaneous recovery usually occurs, but
some patients may have multiple relapses [3,6].
the 2-year treatment period the mass remained the same
size and the lung parenchyma on CT scans of the chest
unremarkable.
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Received for publication 17 August 2000
Accepted in revised form 24 January 2001