Costochondritis

Study objectives: To determine whether bone imaging with [sup.99m]Tc methylene diphosphonate is a specific method of making the diagnosis of costochondritis in patients with chest pain who rule out for myocardial infarction. Design: Nonblinded prospective controlled study in 20 patients and 10 control subjects. Setting: Inpatient medical service of a tertiary teaching hospital. Patients: Two hundred consenting patients admitted to the hospital with chest pain and myocardial infarction were examined. Those whom acute myocardial infarction was ruled out were evaluated for the clinical signs of costochondritis, ie, tenderness over one or more costochondral junctions. Twenty patients who met the clinical criterion gave informed consent and were subjected to bone imaging. Ten control subjects with cancer who did not have clinical signs of costochondritis underwent bone imaging to rule out metastatic disease (normal in all cases). Interventions: Bone imaging with IV [sup.99m]Tc methylene diphosphate. Measurements: Bone scans of the investigative patients and the common subjects were read by two independent nuclear medicine specialists. Results: Sixteen of the 20 patients with clinically diagnosed costochondritis showed increased technetium uptake at all costochondral junctions bilaterally; six of then also had increased uptake elsewhere on the chest wall (sternum, manubrium or first rib). All 10 of the control patients likewise showed increased technetium uptake at all costochondral junctions bilaterally. Conclusions: Bone imaging with [sup.99m]Tc methylene diphosphonate is not a specific method of making the diagnosis of costochondritis.

Key words: bone scans; costochondritis; technetium

Of patients admitted to the hospital with a chief complaint of acute chest pain and suspected acute myocardial infarction, a significant number of those in whom infarction is found not to have occurred appear to have costochondritis as the source of their pain,[1-6] and it may also contribute to the symptoms even if acute coronary disease is present.[4]

Costochondritis is often not considered, or not considered seriously, in the differential diagnosis of acute chest pain, largely because of the "softness" of its clinical diagnostic criterion, namely the presence of marked anterior chest tenderness localized to the costochondral junctions of one or more ribs, without notable swelling, heat, or local erythema (Tietze's syndrome[7] is a more acute form of costochondritis, with local swelling, heat, and erythema). All the studies that have reported a significant incidence of costochondritis in patients presenting with acute chest pain have used this purely clinical criterion, but the physical findings can be obscured by variations in the pain threshold of different patients.

It has been reported that the diagnosis can be documented objectively, in that the costochondritic areas take up technetium tracers ([sup.99m]Tc methylene diphosphonate) in a characteristic pattern.[8-10] We sought to determine prospectively whether this proposed objective criterion is indeed sensitive and/or specific for the diagnosis. The study was approved by the Institutional Review Board of Beth Israel Medical Center, New York.

Materials and Methods

Two hundred consecutive patients admitted to the hospital with a chief complaint of acute chest pain and suspected acute myocardial infarction had the conventional workup, including histo and physical examination, serial ECGs, and three determinations of creatine phosphokinase. Patients in whom acute myocardial infarction was ruled out (no elevation of CPK level and no ECG changes indicative of infarction) had specific physical examination of the chest to document the presence or absence of costochondral tenderness; if present, the anatomic sites of maximal tenderness were documented. A check was also made for tenderness over the sternum, xiphoid process, ribs, intercostal spaces, and pectoralis major. The physical findings were confirmed by a second examiner. The same two examiners (G.M. and H.M.) did all the chest examinations.

Those who fulfilled the clinical criterion for costochondritis gave informed consent to a [sup.99m]Tc methylene diphosphonate bone scan. The bone scan results were reviewed by two interpreters, and uniform radiologic criteria were used to determine positive or negative radioactive uptake. There was agreement between the two readers in all cases. We also studied a control group of 10 patients with cancer who underwent bone scans to rule out metastatic disease; routine hospital consent was obtained. Some did and some did not have chest discomfort, but none had specific costochondral tenderness.

Results

Twenty patients fulfilled the criterion for costochondritis and underwent bone scanning. Sixteen were female and four were male; their ages ranged from 35 to 101 years; the men averaged 63 years and the women averaged 55.5 years.

Sixteen patients had increased costochondral uptake of radioactivity on bone scans; in all of them, the increased uptake was noted in all the costochondral junctions bilaterally (Fig 1), and in six of them, uptake was also noted in various other chest wall structures, such as the sternum, manubrium, and the first rib. In only two patients did the technetium accumulation area conform to the tender area on the physical examination.

The control group of 10 patients who had bone scans to rule out bone metastases (and did not have metastases) showed the same pattern, ie, uptake in all costochondral junctions (Fig 2), despite the absence of clinical findings of costochondritis.

Discussion

Scattered case reports[8-10] have described increased uptake of [sup.99m]Tc methylene diphosphonate at costochondral junctions in patients with a clinical diagnosis of costochondritis. In our study, 16 of 20 patients with clinical costochondritis showed such uptake. However, the same pattern of uptake at costochondral junctions was seen in a control group in which there was no costochondritis. In only two costochondritis patients was there agreement between the location of tenderness on physical examination and the location of increased tracer uptake. Accordingly, our findings indicate that bone scanning with [sup.99m]Tc methylene diphosphonate is not a specific test for diagnosis of costochondritis. The previous studies that reported the usefulness of skeletal scintigraphy for this purpose were essentially anecdotal and did not utilize control subjects. It is possible, though speculative, that some other imaging agent, such as [sup.67]Ga citrate, might yield more specific findings. Preliminary studies in this area are underway.

REFERENCES

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[3] Wolf E, Stern S. Costochondral syndrome: its frequency and importance in differential diagnosis of coronary heart disease. Arch Intern Med 1976; 136:189-91

[4] Epstein SE, Gerber LH, Borer JS. Chest wall syndrome: a common cause of unexplained cardiac pain. JAMA 1979; 241:2793-97

[5] Levine PR, Mascette AM. Musculoskeletal chest pain in patients with `angina:' a prospective study. South Med J 1989; 82:580-85

[6] Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac pain: a study of 100 patients. Arch Phys Med Rehabil 1992; 73:147-49

[7] Tietze A. Uber eine eigenartige haufung von fallen mit dystrophie der rippenknorpel. Berl Klin Wochenschr 1921; 58:829-32

[8] Sain AK. Bone scan in Tietze's syndrome. Clin Nucl Med 1978; 3:470-71

[9] Honda N, Machida K, Mainiya T, et al. Scintigraphic and CT findings of Tietze's syndrome: report of a case and review of the literature. Clin Nucl Med 1989; 14:606-09

[10] Massie JD, Sebes JI, Cowles SJ. Bone scintigraphy and costochondritis. J Thorac Imaging 1993; 8:137-42

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