Chest pain in Lupus - when is it due to costochondritis?
Chest pain in Lupus is a potentially serious condition and can arise because of different problems. These include:
Pleurisy (inflammation of the lung lining)
Pulmonary Embolism (a blood clot)
Pericarditis (heart lining inflammation)
Myocardial infarction or angina due to narrowed or blocked coronary arteries
Any Lupus patient with chest pain should see a doctor right away and the above conditions should be considered and excluded.
A common cause of pain in the anterior chest is costochondritis or inflammation at the insertions (enthesis) of the ribs to the breastbone.
This page deals with this cause of chest pain that is not serious, but important to diagnose correctly for correct treatment and to prevent unnecessary or invasive tests.
Since costochondritis is recurrent and can come on acutely, patients may have frequent emergency admissions so it is important to prevent this.
Other Features of Costochondritis
Because of a "catching sensation" the patient may not breathe deeply enough and thus develop a sensation of breathlessness. However, the lungs and heart are completely normal in costochondritis.
The vast majority of cases with costochondritis have no visible swelling at the rib insertion to the breastbone (sternum).
Because the inflammation may be situated on the inner aspect of the ribs and breastbone the costochondritis may not necessarily be associated with tenderness when the doctor examines the painful region.
In fact the pain can be poorly localised and this results in a careful search to exclude heart or lung disease.
Inflammation relating to the ribs may also be secondary to pain from enthesopathy at rib cage muscles. Each rib from numbers 2 to 11 has at 3 muscles attached to both their top surface and bottom surface. This may be associated with pain over the chest wall at a site well away from the breastbone and may also be hard to localise.
Finally rib enthesis pain may be arising from the joints that knit the ribs to the spine which are called the costovertebral joints and the costotransverse joints.
Illustrative case
A 24 year old man with ANA positive Lupus with a titre of 1/2500 initially presented with a lupus facial rash and hand joint pain and stiffness. He also had severe fatigue.
He was treated with hydroxychloroquine with dose stabilisation at 200mgs/day and had low dose corticosteroid initially.
One year after the diagnosis he developed severe anterior chest pain that came on suddenly.
The pain was worse on breathing.
He experienced shortness of breath on exertion.
He was sent to hospital by his GP and was assessed for a pulmonary embolism.
His clinical examination was normal.
He had a normal ECG, a normal chest X-ray and a normal perfusion scan.
His blood investigations showed to evidence for the anti-phospholipid syndrome that predisposes to clotting including pulmonary embolism.
He continued to feel left sided intermittent chest pain for 6 months.
When he was examined by the Rheumatologist he had no focal tenderness over the ribs at the anterior chest wall and breastbone junction.
His ribcage and spine were also normal on examination.
He had no tenderness elsewhere.
The Rheumatologist could feel a "clunk" or "click" over the left side of chest likely indicating some inflammation of the costochondral joints.
In view of the negative investigations and the clinical story and findings the patient was reassured and advised to take painkillers as needed.
Summary
It is likely that the case above suffered from enthesitis or enthesopathy of the rib attachment to the breast bone.
This can be difficult to diagnose as there is rarely obvious swelling.
Tenderness is variable and when absent making a diagnosis difficult.
So a high level of suspicion is needed.
Costochondritis in Lupus may be an incidental finding not related to the disease.
The case above was completely well otherwise which supports the idea that the costochondritis was independent of the Lupus.
However, Lupus is a great mimic and can occasionally cause costochondritis.
The treatment is pain killers initially.
If a Rheumatologist or other specialist can localise a tender spot then this can be injected with corticosteroids.
An accurate diagnosis helps alleviate patient anxiety about a more serious diagnosis.
The long term outcome for this condition is generally good.
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