Costochondritis, also known as chest wall pain, costosternal syndrome, or costosternal chondrodynia[1] is an acute[2] and often temporary inflammation of the costal cartilage, the structure that connects each rib to the sternum at the costosternal joint. The condition is a common cause of chest pain.[4] Though costochondritis often resolves on its own, it can be a recurring condition that has little or no signs of onset. Costochondritis symptoms can be similar to the chest pain associated with a heart attack.[7] Unexplained chest pain is considered a medical emergency until life-threatening cardiac issues can be ruled out.[7] Severe cases of costal cartilage inflammation that also involve painful swelling are sometimes referred to as Tietze's syndrome, a term sometimes used interchangeably with costochondritis. However, some physicians view costochondritis and Tietze's syndrome as separate disease states due to the absence of costal cartilage swelling in costochondritis. Treatment options are quite limited and usually involve a combination of rest, analgesics, or anti-inflammatory medications.
[8] Cases with persistent discomfort may be managed with cortisone injections[6][8] or surgery may be indicated if the condition is severe. Individuals with costochondritis are typically instructed to avoid strenuous physical activity to prevent the onset of an attack. Pain or tenderness to palpation usually occurs on the sides of the sternum, affects multiple ribs, and is often worsened with coughing, deep breathing, or physical activity.[10] On physical examination, a physician inspects and feels the patient for swollen or tender areas, and can often produce the pain of costochondritis by moving the patient's rib cage or arms.[11] A factor that may aid in the differentiation of costochondritis from Tietze syndrome is the location of the pain on the sternum. Costochondritis typically affects the third, fourth, and fifth costosternal joints in contrast to Tietze's syndrome, which usually affects the second or third costosternal joint.[8] Pain from costochondritis typically resolves within one year.
In most cases of costochondritis, no cause is identified.[6] However, it may be the result of physical trauma (due to direct injury, strenuous lifting, or severe bouts of coughing), associated with scoliosis, ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, or a tumor (benign or cancerous).[13] Infection of the costosternal joint may cause costochondritis in rare cases. Most cases of infectious costochondritis are caused by Actinomyces, Staphylococcus aureus, Candida albicans, and Salmonella. In rare cases, Escherichia coli can be a cause of infectious costochondritis.[14] There is anecdotal evidence of costochondritic chest pain being associated with Vitamin D deficiency in some cases,[15] and multiple anecdotal reports that it could be associated with chest binding, as practiced by some members of the transgender community.[16] It also can be caused by Relapsing Polychondritis. The pathogenesis underlying the development of costochondritis remains unclear. Proposed mechanisms of injury include neurogenic inflammation, muscular imbalance, increased muscular pull on the rib,[12] mechanical dysfunction at the costotransverse joint of the rib,[12] or a derangement of the mechanical structure of the costochondral junction.
Sternum with sternocostal joints and cartilage Other causes of chest pain similar to that produced by costochondritis may include, but are not limited to the following:[7][17] Costochondritis may be treated with physical therapy (including ultrasonic, TENS, with or without nerve stimulation) or with medication. Treatment may involve the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or other pain relief medications (analgesics) such as acetaminophen.[4] Severe cases of costochondritis may call for the use of opioid medications such as hydrocodone or oxycodone, tricyclic antidepressant medications such as amitriptyline for pain from chronic costochondritis, or anti-epileptic drugs such as gabapentin may be used.[19] Oral or injected corticosteroids may be used for cases of costochondritis unresponsive to treatment by NSAIDs; however, this treatment has not been the subject of study by rigorous randomized controlled trials and its practice is currently based on clinical experience.
[20] Rest from stressful physical activity is often advised during the recovery period. Costochondritis is a common condition and is responsible for 30% of emergency room chest pain related visits. One-fifth of visits to the primary care physician are for musculoskeletal chest pain; of this 20% of primary care office visits, 13% is due to costochondritis.[7] Costochondritis cases are most often seen in people older than age 40 and occurs more often in women. ^ a b c ^ a b c d e ^ a b c d e f g hPre-existing hypocalcemia must be corrected prior to initiating therapy with XGEVA®. XGEVA® can cause severe symptomatic hypocalcemia, and fatal cases have been reported. Monitor calcium levels, especially in the first weeks of initiating therapy, and administer calcium, magnesium, and vitamin D as necessary. Monitor levels more frequently when XGEVA® is administered with other drugs that can also lower calcium levels. Advise patients to contact a healthcare professional for symptoms of hypocalcemia.
An increased risk of hypocalcemia has been observed in clinical trials of patients with increasing renal dysfunction, most commonly with severe dysfunction (creatinine clearance less than 30 mL/minute and/or on dialysis), and with inadequate/no calcium supplementation. Monitor calcium levels and calcium and vitamin D intake. XGEVA® is contraindicated in patients with known clinically significant hypersensitivity to XGEVA®, including anaphylaxis that has been reported with use of XGEVA®. Reactions may include hypotension, dyspnea, upper airway edema, lip swelling, rash, pruritus, and urticaria. If an anaphylactic or other clinically significant allergic reaction occurs, initiate appropriate therapy and discontinue XGEVA® therapy permanently. Patients receiving XGEVA® should not take Prolia® (denosumab). Osteonecrosis of the jaw (ONJ) has been reported in patients receiving XGEVA®, manifesting as jaw pain, osteomyelitis, osteitis, bone erosion, tooth or periodontal infection, toothache, gingival ulceration, or gingival erosion.
Persistent pain or slow healing of the mouth or jaw after dental surgery may also be manifestations of ONJ. In clinical trials in patients with osseous metastasis, the incidence of ONJ was higher with longer duration of exposure. Patients with a history of tooth extraction, poor oral hygiene, or use of a dental appliance are at a greater risk to develop ONJ. Other risk factors for the development of ONJ include immunosuppressive therapy, treatment with angiogenesis inhibitors, systemic corticosteroids, diabetes, and gingival infections. Perform an oral examination and appropriate preventive dentistry prior to the initiation of XGEVA® and periodically during XGEVA® therapy. Advise patients regarding oral hygiene practices. Avoid invasive dental procedures during treatment with XGEVA®. Consider temporarily interrupting XGEVA® therapy if an invasive dental procedure must be performed. Patients who are suspected of having or who develop ONJ while on XGEVA® should receive care by a dentist or an oral surgeon.
In these patients, extensive dental surgery to treat ONJ may exacerbate the condition. Atypical femoral fracture has been reported with XGEVA®. These fractures can occur anywhere in the femoral shaft from just below the lesser trochanter to above the supracondylar flare and are transverse or short oblique in orientation without evidence of comminution. Atypical femoral fractures most commonly occur with minimal or no trauma to the affected area. They may be bilateral and many patients report prodromal pain in the affected area, usually presenting as dull, aching thigh pain, weeks to months before a complete fracture occurs. A number of reports note that patients were also receiving treatment with glucocorticoids (e.g. prednisone) at the time of fracture. During XGEVA® treatment, patients should be advised to report new or unusual thigh, hip, or groin pain. Any patient who presents with thigh or groin pain should be suspected of having an atypical fracture and should be evaluated to rule out an incomplete femur fracture.
Patients presenting with an atypical femur fracture should also be assessed for symptoms and signs of fracture in the contralateral limb. Interruption of XGEVA® therapy should be considered, pending a risk/benefit assessment, on an individual basis. Clinically significant hypercalcemia has been reported in XGEVA® treated patients with growing skeletons, weeks to months following treatment discontinuation. Monitor patients for signs and symptoms of hypercalcemia and treat appropriately. XGEVA® can cause fetal harm when administered to a pregnant woman. Based on findings in animals, XGEVA® is expected to result in adverse reproductive effects. Advise females of reproductive potential to use highly effective contraception during therapy, and for at least 5 months after the last dose of XGEVA®. Apprise the patient of the potential hazard to a fetus if XGEVA® is used during pregnancy or if the patient becomes pregnant while patients are exposed to XGEVA®. The most common adverse reactions in patients receiving XGEVA® with bone metastasis from solid tumors were fatigue/asthenia, hypophosphatemia, and nausea.