Vol.2, No.3, 208-210 (2013) Case Reports in Clinical Medicine
http://dx.doi.org/10.4236/crcm.2013.23056
Tietze’s Syndrome in the emergency department: A
rare etiology of atraumatic chest pain
Lee Grodin1*, Gino Farina2
1Department of Emergency Medicine, State University of New York, Downstate Medica l Center, New York, USA;
*Corresponding Author: [e-mail]
2Department of Emergency Medicine, Long Island Jewish Medical Center, New York, USA
Received 29 March 2013; revised 30 April 2013; accepted 15 May 2013
Copyright © 2013 Lee Grodin, Gino Farina. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Tietze’s Syndrome is an uncommon disorder
that presents with painful, tender, non-suppura-
tive swelling of the anterior chest wall. We report
a case of a female patient who presented to the
emergency department with a chief complaint of
atraumatic chest pain and swelling of the ante-
rior chest wall. After a thorough history and
physical examination, as well as basic labora-
tory tests and chest radiography, she was di-
agnosed with Tietze’s Syndrome. The expedient
accurate diagnosis of Tietze’s Syndrome is im-
portant for the physical and emotional well-be-
ing of a patient, and avoids overlooking more
dangerous pathologies. T ietze’s Syndrome needs
to be considered in the differential diagnosis of
a patient presenting with spontaneous swelling
of the anterior ches t.
Keywords: Tietze’s Syndrome; Atraumatic
Chest Pain
1. INTRODUCTION
Chest pain is a frequent chief complaint in emergency
departments, and the underlying pathology ranges from
completely benign to imminently life-threatening. Among
the myriad possible etiologies are the confounding mus-
culoskeletal disorders, which account for 50% of benign
causes [1]. While frequently discussed and included in
differential diagnoses, they are often inappropriately con-
solidated and misunderstood. Tietze’s Syndrome (which
has also been referred to as Costosternal Syndrome, An-
terior Chest Wall Syndrome, Parasternal Chondrodynia,
Thoracochondalg ia, Chondrop athia Tubero se, and Costo-
chondral Junction Syndrome) is an uncommon muscu-
loskeletal pathology, which was first described in 1921
by Alexander Tietze [2-4]. The National Institutes of
Health lists it as a rare disease, indicating the limited
available information about the syndrome as well as its
possible rari t y [5].
While it is a benign, self-limited, chronic pain condi-
tion characterized by a localized swelling involving usu-
ally the second or third ribs, unrecognized it can mimic
malignancies, acute coronary syndrome, pneumonia, or
trauma [6,7]. The emotional and physical relief of an
accurate diagnosis is then delayed and the patient can
undergo an emotionally stressful and costly evaluation
for more serious disease [7,8]. The pain can be tremen-
dous. We present a young female patient with a classic
case of Tietze’s Syndrome. The diagnostic difficulty lies
in part to the absence of confirmatory laboratory or im-
aging tests, thus leaving the clinician reliant on the pa-
tient’s history and presentation.
2. CASE PRESENTATION
A 29 years old otherwise healthy woman presented
with localized right sided chest pain for approximately
three days and focal swelling over the same area for one
to two days. She described the pain as “aching,” local-
ized to the right side of her anterior chest, and radiating
to her back ipsilaterally. It was pleuritic and associated
with subjective shortness of breath, which she attributed
to her pain. It was minimally responsive to ibuprofen.
The swelling was very firm, tender, and had appeared
spontaneously.
She denied trauma, recent travel, or illnesses. She de-
nied fever, chills, malaise, or weight loss. She works as a
visual merchandiser but has had no change in her level of
physical activity.
One year ago, the patient reported she was diagnosed
with Lyme Disease after presenting with malaise and
Bell’s Palsy. After confirmatory serological testing, she
completed a course of antibiotics. At that time she also

L. Grodin, G. Farina / Case Reports in Clinical Medicin e 2 (2013) 208-210 209
underwent evaluation for thyroid dysfunction and fibro-
mylagia, neither of which was diagnostic and her symp-
toms were attributed to Lyme Disease. Her only surgery
was approximately three years ago when she underwent
a small bowel resection secondary to obstructive benign
tumors.
On physical exam the patient preferred to be still in
effort to minimize her pain. The only remarkable finding
was a tender swelling approximately 5 cm in diameter
over her right second and third costocartilages. There
was no discoloration (ecchymosis or erythema) or other
changes to the skin (Figure 1). The swelling was very
firm and non-fluctuant. An electrocardiogram and chest
radiograph revealed no abno rmali ties. H er basic lab wo rk
was within normal limits (CBC, CMP) and her ESR was
2.0 mm/Hour.
The diagnosis was discussed with the patient and her
partner, and various pain management strategies were
offered. In the emergency department she received ke-
torolac and warm compresses. Upon discharge she
elected to continue ibuprofen, at increased doses, as well
as use warm compresses. She was also prescribed oxy-
codone for break through pain.
During follow-up by telephone, the patient reported
she declined to ever seek treatment or further imaging,
and the pain persisted for two to three months, slowly
declining. She has since returned to work and is no
longer using any analgesics.
3. DISCUSSION
A timely diagnosis of Tietze’s Synd rome can expedite
the implementation of an effective treatment regiment,
avoid an anxiety-provoking and costly work up, and re-
duce the possibility of overlooking more serious under-
lying pathologies. Tietze’s Syndrome is rare and few
clinicians have significant experience with it. The etiol-
ogy is mysterious, however, its diagnostic profile has
been crystallizing over the last h alf century.
Figure 1. 29-year-old woman presenting with stereotypical
localized swelling in Tietze’s Syndrome on the anterior chest
wall.
The incidence of Tietze’s Syndrome is not well stud-
ied, but in 1976, a study of 320 patients with precordial
chest pain yielded almost a 10% incidence of Costoster-
nal Syndrome, including Tietze’s Syndrome [3]. It is
most commonly diagnosed in 20 to 50 year old patients,
but can strike young pediatric and elderly patients
[6,9,10]. There is a wide range of sex distribution re-
ported, ranging from equal to twice as common in fe-
males than males [6,7,11,12]. The onset of pain can be
sudden or gradual, and it is often pleuritic or aggravated
my movement [7,11,13]. Supporting the diagnosis is the
chronic, often relapsing and remitting course of Tietze’s
Syndrome and ruling out other possibilities by history,
physical, and imaging [11,14].
The location of the pain and the rarity of the syndro me
lay the foundation for a broad differential diagnosis.
While 70% of cases of Tietze’s Syndrome are unilateral
and affect one joint, it is important to consider neoplastic,
cardiac, respiratory, gastrointestinal, and other muscu-
loskeletal origins [1]. While swelling is considered a
hallmark of Tietze’s Syndrome, it may only indicate the
severity of disease [15]. Several cases of malignancy
misdiagnosed as Tietze’s Syndrome have underscored
the importance of making an accurate diagnosis [16-22].
In addition one must be wary of the possibility of con-
current cardiac pathology [23].
In recent decades imaging has become an invaluable
resource for clinicians, yet it is still not diagnostic of
Tietze’s Syndrome. While radiographs help minimize the
concern for bone pathology, they are generally com-
pletely normal. Computer tomography scanning, bone
scintigraphy, ultrasound, and magnetic resonance imag-
ing have shown more helpful distinctions. A 2008 study
recommends MRI and a 2010 r ev iew recommen d ed bo ne
scintigraphy and ultrasound as screening tests [11,15].
There have been some histological inquiries, but the
studies have thus far deemed histology to be unrevealing
or unimportant [3,6,12].
Treatment for Tietze’s Syndrome is supportive, with
the mainstay of NSAIDs and application of heat or cold
[13]. For refractory cases, corticosteroid injections may
be considered [15].
4. CONCLUSION
Tietze’s Syndrome is an idiopathic chronic pain con-
dition, which is rarely seen in emergency departments. It
presents with atraumatic chest pain and a focal swelling
of the anterior chest wall. Current epidemiology suggests
that its prevalence is highest among patients between 20
and 50 years of age. Accordingly it is important to con-
sider Tietze’s Syndrome and other musculoskeletal di-
agnoses in patients of this age range. Older patients pre-
senting with chest pain are more likely cardiac, pulmo-
nary, or neoplastic etiologies. The accurate diagnosis of

L. Grodin, G. Farina / Case Reports in Clinical Medicin e 2 (2013) 208-210
210
[11] Volterrani, L., et al. (2008) Magnetic resonance imagine
in Tietze’s Syndrome. Clinical and Experimental Rheu-
matology, 26, 848-853.
Tietze’s Syndrome provides the best platform for pain
management, reducing the time and cost of an unneces-
sary work up for other conditions while not overlooking
malignancies. It provides the patient with physical and
emotional comfort. While a thorough history and physic-
cal are essential for diagnosis, follow up is helpful to
ensure the disease course is consistent with Tietze’s
Syndrom e an d not suggestive of another pathology .
[12] Landon, J. and Malpas, J.S. (1959) Tietze’s Syndrome.
Annals of Rheumatic Disease, 18, 249-254.
doi:10.1136/ard.18.3.249
[13] Semble, E.L. and Wise, C.M. (1988) Chest pain: A rheu-
matologist’s perspective. Southern Medical Journal, 81,
64-68. doi:10.1097/00007611-198801000-00014
[14] Langford, C.A. and Mandell, B.F. (2012) Chapter 336.
Arthritis associated with systemic disease, and other ar-
thritides. In: Longo, D.L., et al., Harrison’s Principles of
Internal Medicine, The MacGraw-Hill Companies, Inc.,
New York, 2858 -2859.
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