The efficacy of oral corticosteroids for treatment of Tietze syndrome: A pragmatic randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: Tietze syndrome is a rare form of chest wall costochondritis with joint swelling which can cause significant chest pain and decline in ability of daily activities. There is no standardized treatment protocol. The aim of this study was to assess the efficacy of adding oral steroids in addition to other non- steroidal treatment in improvement of pain and quality of life (QOL) in patients with Tietze syndrome. METHODS: Forty patients with Tietze syndrome were randomly divided into two treatment groups: (1) One week of prednisolone 40 mg daily followed by 1 week of prednisolone 20 mg daily followed by 1 week of 10 mg with 3 weeks of non-steroidal anti-inflammatory drug (NSAID) treatment (n = 20); (2) three weeks of NSAID treatment only (n = 20). A symptom questionnaire was used to rate the major symptoms of Tietze syndrome and costochondritis: Numeric rating scale (NRS) for pain on a scale of 0 (no pain) to 10 (severest pain); the resulting global symptom score was used to evaluate the efficacy of treatment with assessment of joint swelling resolution. The EQ-5D-5L instrument for measurement of QOL was used. Assessments were made on intention to treat basis at baseline and at 1, 2 and 3 weeks followed by a medium term follow period after treatment cessation. The trial was registered at www.isrctn.com ISRCTN11877533. RESULTS AND DISCUSSION: There was a significant drop in mean NRS pain scores between the groups at 1, 2 and 3 weeks in favour of the steroid group (46.8% vs. 17.7%; p < 0.001, 56.3% vs. 35.8% p < 0.001 and 65.4% vs. 46.7% p < 0.001 respectively). There was a 25.8% (95% CI 13.2-38.8) difference in mean NRS score drop at a median of 6.5 months after treatment cessation in favour of the steroid group over the NSAID only group. Only three cases of mild GIT upset in the steroid group and two cases of mild nausea were reported in the NSAID group. There was an improvement in QOL using the median EQ-5D-5L scoring at 3 weeks in favour of the steroid group 7 (7, 8) versus 10 (8.5-11), (p < 0.001). The improvement in pain scoring and QOL did not correlate with improvement in joint swelling at 3 weeks after treatment with 2/20 (10%) in the steroid arm versus 1/20 (5%) in NSAID arm having an obvious improvement (p = 0.393). WHAT IS NEW AND CONCLUSION: In this study, addition of short-term oral corticosteroids showed a clear benefit for use at 1, 2 and 3 weeks in improvement of pain and QOL in patients with Tietze syndrome. This difference was maintained at mid-term follow up after treatment cessation. This facilitates the advantage of using steroids as well as excluding their side effects for an accepted timeframe.

External application of two unrestricted herbal medicines to treat costochondritis in a young collegiate athlete: A case report.

Costochondritis (ChC), especially chronic ChC, typically manifests as spontaneous vague pain in anterior chest area and often occurs in adolescents for unknown reasons; it has prevented many collegiate athletes from participating in physical training and competitions. A 21-year-old female collegiate taekwondo athlete suffering from chronic chest pain was sent by her coaches for diagnosis and treatment. Seated motion palpation was used to identify spontaneous and motion-involved pain areas. Palpation in the supine position was used to initially rule out breast diseases. X-ray, electrocardiogram, and cardiac Doppler ultrasound were used in conjunction with myocardial enzyme testing to rule out lung and cardiovascular diseases. The patient was treated using herbal medicines applied via an external patch. The medicine was comprised of Rhizoma Corydalis and borneol, and the treatment lasted for seven weeks. For five weeks patches were applied at a frequency of two or three times per day, followed by a two-week period of once per day. The patient reported that the pain was relieved after two weeks of external herb use, and the autonomic chest pain had resolved. Re-examination after one month showed that her upper limb range of motion was close to normal, and her psychological burden had almost disappeared. It is possible to seek more active medicinal treatment and more practical external products for young athletes who is suffering chronic ChC that affects the sport training and competitive performances.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: The use of corticosteroids in the management of costochondritis.

A short cut review was carried out to establish whether there is any evidence that for the use of corticosteroids in the treatment of costochondritis. No papers were found using the reported search. The clinical bottom line is that further research is needed in this area.

[Soft tissue swelling of the sternoclavicular joint]. / Weichteilschwellung des Sternoklavikulargelenks.

A 73-year-old woman presented with a swelling of the right sternoclavicular joint the size of a hens egg which had persisted for 2 years. After a corticosteroid injection 8 months previously the swelling was asymptomatic. The magnetic resonance imaging (MRI) scan showed synovialitis of the sternoclavicular joint with edema of the adjacent bone. The constellation is indicative of Tietze syndrome, an inflammation of costochondral junctions of the ribs or chondrosternal joints. The treatment is usually directed at pain relief and benign conditions are often self-limiting.

Meticillin-sensitive Staphylococcus aureus costochondritis in a healthy man.

BACKGROUND: A 54-year-old previously healthy white man presented to hospital with fever, right parasternal pain and swelling over the right second and third costochondral joints. The symptoms had developed 1 week earlier. INVESTIGATIONS: Physical examination, white blood cell count, erythrocyte sedimentation rate, C-reactive protein level, blood and urine culture, plain radiography and CT of the chest, (99m)Tc bone scintigraphy, ultrasound-guided needle aspiration of soft tissue mass, Gram staining and culture of aspirated fluid. DIAGNOSIS: Meticillin-sensitive Staphylococcus aureus costochondritis. MANAGEMENT: CT revealed a 2 x 5 cm soft tissue mass at the posterior aspect of the right second and third costochondral joints. The fluid aspirated contained Gram-positive cocci, and culture revealed the presence of meticillin-sensitive S. aureus. The patient received a 6-week course of flucloxacillin (2 g by intravenous injection every 6 h for 2 weeks, then 1 g orally every 6 h for 4 weeks). He responded well to treatment, and was discharged from hospital.

Intra-articular glucocorticoid injection: an unusual cause of transient hypophosphataemia.

We describe a case of symptomatic hypophosphataemia following an intra-articular glucocorticoid injection.

Can early diagnosis and management of costochondritis reduce acute chest pain admissions?

OBJECTIVE: We identified patients presenting with chest pain diagnosed as costochondritis by a consultant rheumatologist. The time taken to diagnosis was determined and the influence of diagnosis on subsequent management was assessed. We then estimated any cost benefits that early diagnosis and treatment of costochondritis might confer. Finally, we evaluated our current experience of sulfasalazine as a treatment for recurrent costochondritis. METHODS: This was a retrospective observational study of 25 consecutive patients (17 female), mean age 50 years (range 26-75), with costochondritis who initially presented with acute chest pain. RESULTS: The mean time to diagnosis was 9.4 (0-57) months. The total number of chest pain admissions pre-review was 39 compared with 6 post-review (p < 0.0001). The number of minor investigations was 169 pre-review compared with 17 post-review (p < 0.0001), and major investigations 30 compared with 0 (p < 0.01). All 13 patients treated with corticosteroid injections reported symptomatic improvement, and 10 of the 11 whose symptoms recurred responded to sulfasalazine. CONCLUSION: Patients with costochondritis frequently present with acute chest pain, often resulting in multiple admissions and investigations. In this study admission and investigation rates were significantly reduced following rheumatological review. How much of this reduction is directly a result of rheumatological intervention is unclear, given the limitations of the study. The findings suggest early review may improve patient care and reduce expenditure; in recurrent cases of costochondritis, sulfasalazine may be of additional longterm benefit.

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.

Scintigraphic and CT findings of Tietze's syndrome: report of a case and review of the literature.

A case of Tietze's syndrome is reported. A 43-year-old woman, who had experienced right anterior chest pain and tender swelling of the right first costosternal junction for seven months, showed increased accumulation of the right first, the right fourth, and the left first costochondral junction on bone imaging. Ga-67 imaging showed increased accumulation at the right first costosternal junction. CT showed sclerosis of the sternal manubrium, partial calcification of costal cartilage, and soft tissue swelling. Biopsy of the right first costal cartilage showed chronic inflammation with fibrosis and ossification. Increased uptake of bone gallium imaging is consistent 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.

Effects of human calcitonin on pain in the treatment of Tietze's syndrome.

Tietze's syndrome consists of pain, tenderness, and swelling of the costosternal or sternoclavicular joints. The etiology is unknown, although microtrauma or rare infections have been though to be responsible for the lesion. Conventional therapy consists of anti-inflammatory drugs, sometimes combined with chemotherapeutic agents and antibiotics. Surgery is usually deemed necessary for cases that do not respond to conventional therapy. Experience with the use of human calcitonin in five patients suffering from severe Tietze's syndrome who did not respond to conventional therapy is reported. Symptoms improved within seven days, and all symptoms and signs had disappeared after one month of treatment. The beneficial effects of calcitonin are believed to result from the hormone's well-known analgesic and immunomodulating effects.

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.