Tietze's syndrome was initially described almost 100 years ago and is an inflammatory process affecting the costochondral cartilages [1] [2] [3]. The etiology and pathogenesis are yet to be elucidated but it is most frequently diagnosed in adults less than 40 years of age who suffer from numerous conditions of rheumatic and non-rheumatic origin [1] [2]. Rheumatoid arthritis (RA), seronegative spondyloarthropathies, trauma, various infections (tuberculosis, brucellosis) and malignant diseases (multiple myeloma, chondrosarcomas, local invasion of breast and lung tumors, but also metastatic dissemination) are mentioned as disorders that may cause Tietze's syndrome [1] [3] [4]. Although it is often mistaken with costochondritis, however, several well-established features distinguish the two clinical entities [4]. The clinical presentation of Tietze's syndrome is demarcated by swelling and tenderness of the costosternal, costochondral and/or sternoclavicular joints, suggesting that the upper ribs are more commonly affected, whereas the manubrium of the sternum and the xiphoid process are rarely involved [1] [2]. Costochondritis, on the other hand, develops in older adults (> 40 years of age) and without swelling of the adjacent tissues [4]. Moreover, only one costal cartilage exhibits inflammatory changes (either the third or second rib) in 80% of patients with Tietze's syndrome, while multiple sites are affected in more than 70% of patients suffering from costochondritis [2] [3] [4]. In addition, one of the most important features of Tietze's syndrome is pain at the site of inflammation, which is often aggravated by coughing, deep breathing or lying prone [1] [2] [4]. Although this syndrome is benign, a relapsing/remitting course is observed, as pain can disappear spontaneously and then reappear and be present for weeks or months, often followed by swelling [1].

• Asymptomatic

  She received medical and surgical therapy and 5 months later, she was asymptomatic. [ncbi.nlm.nih.gov]

• Chest Pain Radiating to the Arms

  It usually comes on abruptly, with chest pain radiating to your arms or shoulder and lasting several weeks. Tietze syndrome is accompanied by a localized swelling at the painful area (the junction of the ribs and breastbone). [webmd.com]

• Soft Tissue Mass

  tissue mass, Gram staining and culture of aspirated fluid. [ncbi.nlm.nih.gov]

• Chest Wall Pain

  Costochondritis is sometimes known as chest wall pain, costosternal syndrome or costosternal chondrodynia. Sometimes, swelling accompanies the pain (Tietze syndrome). Costochondritis usually has no apparent cause. [mayoclinic.com]

• Rib Tenderness

  Symptoms include: a sharp pain in your upper ribs tenderness around the area of your upper ribs swelling around the area of your upper ribs Sudden movements of your ribs, during physical activity or when you cough or sneeze, may make the pain worse. [hse.ie]

  Palpation of Costosternal Joints and Symptom Provocation with Movement Patient Palpation Rib Tenderness Thoracic Extension Deep Inhalation Full Exhalation CPA C7–T7 Costotransverse PA 1–7 1 Rt R2–4 Yes Yes Yes C7–T4 Rt 1–2 2 Lt R3–6 Yes Yes Yes C7–T6 [ncbi.nlm.nih.gov]

• Chest Wall Tenderness

  Coronary artery disease is present in 3 to 6 percent of adult patients with chest pain and chest wall tenderness to palpation. [ncbi.nlm.nih.gov]

• Non-Cardiac Chest Pain

  Tietze's syndrome ; www.whonamedit.com Lanham DA, Taylor AN, Chessell SJ, et al ; Non-cardiac chest pain: a clinical assessment tool. Br J Hosp Med (Lond). 2015 May76(5):296-300. doi: 10.12968/hmed.2015.76.5.296. [patient.info]

• Right Anterior Chest Pain

  A 21-year-old collegiate volleyball player had right anterior chest pain and midthoracic stiffness of 8 months duration. [ncbi.nlm.nih.gov]

• Chest Pain

  Costochondritis (with unknown cause) is a common cause of chest pain in children and adolescents. It accounts for 10% to 30% of all chest pain in children. Annually, doctors evaluate about 650,000 cases of chest pain in young people ages 10 to 21. [webmd.com]

  The condition is a common cause of chest pain. [en.wikipedia.org]

  Outpatient diagnosis of acute chest pain in adults. American Family Physician. 2013;87:177. [mayoclinic.com]

• Localized Chest Pain

  While both costochondritis and Tietze syndrome feature symptoms such as localized chest pain and tenderness, Tietze syndrome also causes swelling over the ribs and cartilage near the breastbone (sternum). [medicinenet.com]

  The condition causes localized chest pain that you can reproduce by pushing on the cartilage in the front of your ribcage. Costochondritis is a relatively harmless condition and usually goes away without treatment. [webmd.com]

• Distractibility

  Self‐Mobilization Timed With Breathing ( Figure 1 ) Hypomobile T2–7 8/8 8/8 Seated distraction upper/mid thoracic mobilization/manipulation Thoracic flexion/extension self‐mobilization timed with breathing ( Figure 1 ) Tight pectoralis major/minor 8/ [ncbi.nlm.nih.gov]

• Cervical Radiculopathy

  Reliability construct validity, and responsiveness of the neck disability index, patient-specific functional scale, and numeric pain rating scale in patients with cervical radiculopathy. [ncbi.nlm.nih.gov]

The diagnosis of Tietze's syndrome may be difficult to make without a properly obtained patient history, which provides important clues regarding the onset and course of symptoms. Furthermore, swelling and pain can be assessed only if a thorough physical examination is performed, and the exact location of pain is identified during palpation of the chest wall. Tietze's syndrome is considered to be a diagnosis of exclusion, making imaging studies an essential component during workup [1]. Various techniques have been evaluated for their benefit in diagnosing Tietze's syndrome, including plain radiography, computed tomography (CT) and ultrasonography (US), all showing limited use [2] [3]. Magnetic resonance imaging (MRI) and bone scintigraphy, on the other hand, are currently recommended due to their ability to show inflammatory changes in the cartilage, and also because they are able to exclude other etiologies (tumors, abscesses, etc.) [2] [3]. Certain reports, however, suggest that a biopsy is the only reliable method to confirm the clinical suspicion of Tietze's syndrome, typically revealing nonspecific findings (increased vascularity, patchy loss of ground substance and degenerative changes) on histological examination [2] [5].

• Pseudomonas

  Abstract The dramatic increase in the number of heroin addicts has led to an increase in the number of infective complications seen, especially those due to Pseudomonas aeruginosa and Candida albicans. [ncbi.nlm.nih.gov]

1. Gijsbers E, Knaap SFC. Clinical presentation and chiropractic treatment of Tietze syndrome: A 34-year-old female with left-sided chest pain. Journal of Chiropractic Medicine. 2011;10(1):60-63.
2. Volterrani L, Mazzei MA, Giordano N, Nuti R, Galeazzi M, Fioravanti A. Magnetic resonance imaging in Tietze's syndrome. Clin Exp Rheumatol. 2008 Sep-Oct;26(5):848-53.
3. Fioravanti A, Tofi C, Volterrani L, Marcolongo R. Malignant lymphoma presenting as Tietze's syndrome. Arthritis Rheum. 2002;47(3):229-230.
4. Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80(6):617-620.
5. Kaplan T, Gunal N, Gulbahar G, et al. Painful Chest Wall Swellings: Tietze Syndrome or Chest Wall Tumor? Thorac Cardiovasc Surg. 2016;64(3):239-244.