By itself costochondritis may not be a very dreadful disease but somehow it shares the fame of heart and lung ailments and keeps the doctor on the toe. The diagnosis is also almost one of exclusion, except for a mild tenderness as a specific sign which may or may not be present. The location and sometimes the severity of pain of pain is such that it keeps the medical staff awake. In past few months I had some similar experiences which I would like to share with medical fraternity and invite valuable suggestions and comments.
Background
I am a medical practitioner employed with the Indian Army and have the fortune of serving in such difficult terrains that is a life time experience. I am responsible for the health of around 1200 troops and some local population living near the unit location, (which are very few in most places). I have recently come to a new location with my troops which is in a high altitude area(9000 to 13000 feet) and temperatures ranging from 40 C to -120 C. After coming here the pattern of ailments presenting to me has changed quite a lot. And apart from high altitude problems it is the large no costochondritis cases which intrigues me a lot. Since being in a peripheral remote area I have a very limited stock of equipment and medicines and also evacuation of a serious patient especially at odd hours becomes a difficult task, such a case definitely adds on to my anxiety and patient’s agony. One may be excellent in clinical judgement and clinical skills but when it comes to managing a patient in such a remote area and when life of an individual is at stake, it is always problem situation.
Here I shall discuss in detail some of the cases that I have encountered and and I shall be glad to receive comments on the same and also similar instances which others might have encountered.
CASE 1
16 Apr 08, 1900 hrs
35 yrs old male presented with sudden onset chest pain, on the left side for past 15 min
Brief history—
Patient was apparently asymptomatic about 15 min back when he started experiencing severe pain lt side of chest approximately 2 cm below the left nipple, while he was on a phone call to his home . he dropped the call and came to the emergency room walking.
Pain was pricking in character, severe in intensity
Localized, No radiation
Not related with exertion of any kind
Not related with food, posture or respiration
Constant nagging kind of dull pain was persisting with bouts of severe pain at 1-2 minutes interval was recurring
There was no heaviness of chest or respiratory discomfort complaint
There was history of nausea but no vomiting
There was no history of associated sweating, giddiness, epigastric burning, pain in arms, or fear of death.
There was no history of fever, cough , sore throat, abdominal discomfort, indigestion, local injury.
Past history - no past history of similar complaints. No history any systemic disease in the past however the patient gave history that he had an injury dring a vehicle accident about 6 months back during which he suffered a contusion in the chest on left side which healed in 7-10 days with no residual disability.
Family history – Individual gives no history of any heart ailments or premature deaths in the family.
Personal history – Individual does not consume alcohol or tobacco in any form. In dividual does not have any serious family or personal problems or cause for anxiety. Before coming to the unit location the individual went through one stage acclimatization at 9000 ft.
On Brief Examination –
Patient was lying in bed, was in considerable pain, fully conscious and well oriented.
Pulse – 88/ min, regular normal volume
BP – 124/78 mm Hg, RAS
Resp rate – 16/min, regular, abdominothoracic
No pallor , icterus , cyanosis, pedal edema, clubbing, koilonychias, JVP not raised.
CVS examination – precordial inspection, palpation - -NAD
S1, S2 normal, no murmurs heard.
Resp, CNS, Adominal examination – NAD
Local Examination (Chest Lt) - no signs of inflammation seen, no deformity, respiratory movements equal on both sides, no local tenderness.
Provisional diagnosis – Musculoskeletal chest pain
Treatment started – Inj Voveran 50 mg im stat
Tab ciprofloxacin 500 mg BD
Tab Voveran 1 TDS
16 Apr 08 1930 hrs
Patient started complaining of excruciating pain at the same location and started crying for help.
Started having increased nausea. The character of pain was same and there was complaint of associated giddiness or sweating. Started complaining of burning in the chest, drying of mouth and increase of pain with inspiratory movement.
Differential diagnosis – Myocardial Infarction
Pleuritis
Tietze’s syndrome
Patient was started on - Iv life line
Inj morphine 5 mg at 15 min interval to a total of 15 mg
Tab Disprin 325 mg chewed stat
Tab Clopidogrel 75 mg x4 stat
Pulse, BP monitored every 2 minutes
16 Apr 20008 2030 hrs
No response even after administration of morphine (15 mg), instead the pain got worse and it was decided that the patient be evacuated to the nearest hospital with ECG and X-ray facilities. Patient was taken by road to the hospital, ECG taken which came out to be normal, X – ray chest - NAD, TLC – normal.
Patient admitted and continued on same management with no further pain relief. Patient responded
at about 0030 hrs with slight relief in pain and subsequently slept at 0100 hrs.
Discharged from hospital after 3 days.
Final Diagnosis – Costochondritis
CASE 2
18 Apr 08 1200 hrs
28 yrs old male presented with complains of chest pain left sided, localized at 3cm above nipple, moderate in intensity and pricking in nature. Pain started while the individual was climbing uphill on foot with about 20 kg backpack at an altitude of about 9500 feet on sunny day (temp approx 150C). There was no history of giddiness but the patient felt very weak and exhausted. No history of sweating, nausea, vomiting, respiratory discomfort.
On examination - NAD
Provisional diagnosis – Costochondritis
Patient was started on oral NSAIDs and antibiotics.
Responded within 3 days of tereatment.
Final diagnosis – Costochondritis
CASE 3
24 yrs old male presented with the complaints of left sided chest pain with radiation to the left jaw for past 2 days. Pain started when the patient was employed at sub zero temperature at an altitude of approximately 10,000 feet. Pain was pricking in character, mild to moderare in intensity and severe pain occured in bouts which recurred every 30 min to 1 hr. No relation of the pain with respiratiory movements or exertion or posture. On examination he was found to have mild tenderness over the third costal cartilage on the left side. Started on conservative treatment with NSAIDs antibiotic cover and bed rest. Was brought down to lower altitude and warmer temperatures. Responded in about 4 days.
Final diagnosis - Costochondritis
Discussion
All the patients mentioned herein were previously helthy and have recently come to the above mentioned high altitude cold climate area within past 1 month. And moreover these are only a few of the total cases that have come to me during the past 1 month. There has been a sudden increase in the chest pain cases coming to the emergency room since the time this unit has shifted to high altitude area. Infact there had been no chest pain cases in past 6 months. Does this mean that there is a definite correlation between high altitude area or cold climate with increased incidence of costochondritis?
It is believed that costochondritis cases are sometimes caused by microbial agents, hence the use of antibiotics. That should mean a prevalence of infection in this area where the troops are getting infected and suffering. But in contrast the local population residing in this area does not report incidence of such cases (crude data only, not authentic). So how do we explain infection as the cause ?
Valuable comments and suggestions are invited from all readers. Thank you for sparing valuable time reading this article.
Dr Arun
email : gotoarun@yahoo.com
