Yesterday, I had the first twinge of pain in my ribs that I’ve had in about a year. Immediately I laid down and meditated for about a half hour. I also took a couple of Tylenol. The pain went away later in the afternoon and I realized that the previous day I had been under a lot of stress. I began to wonder how much the stress had to do with my sudden attack of chest pain.

Breast Bone Pain Caused by Insurance Company?

The cause of my stress was an insurance company. To be more precise, I’d had a small grease fire in 2002. It’s funny how in some stressful situations, the brain seizes up; I couldn’t remember for the life of me how to put out a grease fire. So I called 911 and asked them. “Ma’am,” the operator said. “You should get out of the house and let the firefighters deal with it–grease fires can explode without warning.” Well, I exited the house and lucky for me I did, because the pan exploded after I stepped out of the kitchen. The resulting fire caused $8,000 worth of damage. The insurance company paid for the damage and that was the end of the story. Or so I thought.

Fast forward a few years. In the meantime, the insurance company sold the claim to a subrogation company who sued me for the $8,000 for “negligence,” which of course wasn’t true (I’d done all the right things, including calling 911). To cut a long story short, they sent all of the notices of the court hearings to an old address and received a default judgment against me for $14,000 (including lawyer’s fees and court costs) because I didn’t show up for court. Of course I didn’t show up: I never received a notice! I only found out about the judgment when I checked my credit report.

Perhaps you can imagine why I felt a little stressed–I am now on the hook for $14,000 only because a law firm sent notices to an old mailing address and didn’t give me the opportunity to appear in court.

“Psychological Stress is a Cause of Tietze’s Syndrome”?

Wikipedia stated that psychological stress is a cause of Tietze’s Syndrome:  “Preceding stressful events such as relationship problems, family issues or work related stress are very commonly associated with this syndrome.” I’m always skeptical of anything I read on Wikipedia–I think because it got drummed into me in grad school that I could not, under any circumstances, list Wikipedia as a resource for anything–not even in a paper debating the merits of Wikipedia. So I decided to do a little research to find out why that statement on Wikipedia might be true.

Now, I’ve got no doubt that stress can worsen Tietz’es Syndrome. But cause it? That’s like saying that stress can cause arthritis (because Tietze’s and arthritits are closely related). I am fully aware that I have to avoid stress, because tension in my chest is going to affect my costal joints and cause pain. But I’d hate to think there are people out there with Tietze’s syndrome who are living with debilitating pain because of a little stress fifteen years ago. As far as I am aware, there are many causes of Tietze’s syndrome like genetics and viruses (you can read a full summary of known causes of Tietze’s syndrome here). But “stress”? It just doesn’t seem likely to me that stress can cause a joint to swell. Or could it?

Tietze’s Syndrome: Searching for Answers

I looked for answers starting with a Google search for stress & Tietze’s syndrome. Of course, the top article was Wikipedia, followed by a lot of opinion sites like “Jim’s health site” and “Sue’s pain blog.” There was nothing to substantiate that Wikipedia statement from a verifiable source (i.e. something that referenced a medical journal or other good source). I went to PubMed next and performed a search there.

I found one article stating that chest pain can cause anxiety, but not the other way around. Another article said that chest pain can be caused by stress fractures, but not “stress”. Another article talked about chest-related musculoskeletal pain after heart surgery, referring to it as “mechanical stress” i.e. trauma to the chest wall. But not one article mentioned stress itself as a cause.

Tietze’s Syndrome: Wikipedia Corrected

My conclusion is that I have no idea where that statement in Wikipedia came from. It wasn’t referenced, and I could not find anything in PubMed to substantiate it (PubMed is perhaps the most comprehensive medical database there is) to indicate that stress is a cause of Tietze’s syndrome. So for those of you who are wondering if you somehow caused your Tietze’s syndrome by being too high strung or if you brought it on yourself by “stressing out” then relax: you didn’t.

I changed the Wikipedia article to read “Psychological stress can exacerbate Tietze’s Syndrome, but it is not a direct cause.” Of course, someone will probably jump in and change it back. We’ll see if that happens.

References

Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002;32(4):235-50.

Jensen, S. Musculoskeletal causes of chest pain. Aust Fam Physician. 2001 Sep;30(9):834-9

Szántó D, Szücs G, Bíró BP, Priska M. [Degenerative chondroarthropathy of the sternocostal joint following heart surgery]

[Article in Hungarian] Orv Hetil. 1994 Nov 27;135(48):2639-42.

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Breast Implants Can Cause Tietze’s Syndrome

One breast cancer survivor who had reconstructive surgery (with large breast implants) ended up suffering from Tietze’s syndrome due to the large implants rubbing against her ribs. The journal Clinical Nuclear Medicine article about this case can be found here.

Skin Cancer can Mimic Tietze’s Syndrome

One unfortunate patient, diagnosed with Tietze’s syndrome, found out that although his symptoms were identical to Tietze’s syndrome, further diagnostics revealed he actually had skin cancer which had invaded his inner chest. You can find the research article here.

Malignant Tumor Causes Tietze’s Syndrome

There’s at least one person out there who is glad he didn’t accept a diagnosis of Tietze’s syndrome. The patient described in this paper had typical symptoms of Tietze’s syndrome–pain in one left costal cartilage. After a biopsy, it was revealed he had Pleomorphic T-cell lymphoma: cancer. The paper mentions that while an MRI or CT scan could have caught the tumor, X-rays could not.

Can E-Coli Cause Tietze’s Syndrome?

According to this article that appeared in the Scandinavian Journal of Infectious Diseases, a bout of e-coli in a diabetic woman led to a severe case of costochondritis. Although different, Tietze’s syndrome is closely related to costochondritis, so it isn’t so far fetched to think that E-Coli could occasionally cause the disease.

These cases are so rare, they only appeared once in the medical journals. If you are looking for more common causes of Tietzes syndrome, check out this article.

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In February, 1992, I traveled to Ireland on a ferry from Hollyhead to Dublin, a wave-riding roller coaster that took a nauseating 2 hours. I was on my way to a dog show, with a fellow dog breeder called Gwen. We knew each other only from seeing each other at a dog show every few weeks, and I wouldn’t say we were “friends,” but we had our love of Siberian huskies in common, and thus had a lot to talk about.

Tietze’s Syndrome Symptoms Appear

Six weeks after I returned home from the trip to Ireland, I sat on a friend’s couch watching Star Trek: The Next Generation when a crushing pain enveloped my chest. My friend must have seen my pale face, because she asked “Are you OK?” I wasn’t okay. I was in so much pain, I could hardly speak. I’ve given birth three times (all natural births), and childbirth had nothing on the searing pain I was experiencing in my chest. Convinced I was suffering from a heart attack, I said “you need to drive me to the ER.”

My friend rushed me into the ER, and Ihad the sickening, strange feeling that I was not going to make it out of the ER. After I described my symptoms (crushing chest pain), I had a heart-attack work up, and an X-ray to check for blood clots, and finally, after the major tests were negative, a dose of Valium that rendered me stupid enough to actually enjoy wandering around at WalMart with my friend, not buying anything. Don’t get me wrong–I was still in agony–but the hefty dose of Valium made me feel great about the pain.

Pain From Tietze’s Syndrome Hangs on

I took six weeks off of work, unable to move or sleep properly. It hurt to get out of bed. It hurt to get dressed. I couldn’t function without Valium to ease the pain. My then-husband, John, became irritable by the end of week 1, telling me to “stop feeling sorry for myself.” By week four, doctors began to suspect some kind of “underlying psychiatric disorder,”  and John told to “shut the fuck up” when I whined about my ailment.

Granted, I did a lot of whining. It felt like someone was shoving a red hot poker in my ribs. Sometime around week 5, John kneed me in the face because he was “sick of my whining.” The following morning (and here is the karmic retribution), he woke up yelling in agony, screaming that he couldn’t get out of bed because he was in so much pain. My impatient, ill-tempered then-husband had caught Tietze’s disease himself.

I packed my bags and left.  I never saw John again. A friend called me a few years back to tell me John had died of a stomach bleed, most probably caused by the copious amounts of Advil and Motrin he was consuming for the pain. I’m just thankful that I found out what the disease was (and therefore learned other techniques of controlling it) before it was too late.

The big clue to the origin of my disease came about six months after I left my husband. I realized that I hadn’t seen Gwen (the lady who had accompanied me to Ireland) in many months. In fact, no one had seen nor heard of her since the Irish trip. I called her on the phone and asked her if she had any plans to go to any shows in the near future. She said no. “I came down with a disease,” she said. “I’m in so much pain…I can’t do anything.”  I discovered we had the same ailment. Like me, Gwen had come down with Tietze’s syndrome a few weeks after our return from Ireland. Add that to my John coming down with the disorder six weeks after I returned home, and we had out answer: our Tietze’s syndrome was caused by a virus.

The question on my mind at that point, was now that I knew what it was, how do I treat it? It took several years for me to answer that question, and you can find out what I did in this blog post on Treatments.

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The answer might surprise you; although researchers have yet to figure out exactly what causes Tietze’s Syndrome, they have some pretty good ideas, from as benign as coughing to as frightening as cancer. More than one of the following conditions in combination may cause Tietze’s Syndrome and it’s often hard or even impossible to pinpoint an exact cause.

Trauma, Recurrent Microtrauma, or Intercostal hematoma.

A fast, unexpected movement could cause a pool of blood—a bruise—to form in the costal cartilage. Bruises (hematomas) in the cartilage joining the ribs to the breast bone (the intercostal area) have been seen in baseball players, but it could be cause by something as simple as shaking a rug. Recurrent episodes of microtrauma to the chest wall; boxing, karate and other martial arts, severe vomiting and/or coughing, are examples of where the chest could experience continuous trauma, but it could be as simple as lifting heavy objects in an awkward fashion over time.

Fibromyalgia.

Fibromyalgia is a chronic, disabling disorder that occurs in about 2% of the population, and is seen more in women that in men. The causes of fibromyalgia is not known, but significantly higher levels of substance P (a neurotransmitter responsible for transmitting pain signals) have been found in the spinal fluid of patients with fibromyalgia. The inflamed costochondral margins that are commonly associated with Tietze’s Syndrome are the same as two of the pressure points associated with fibromyalgia; it’s therefore important that all of a patient’s symptoms are taken into account when making a diagnosis of Tietze’s syndrome.

Arthritis and related diseases.

Rarely, patients with psoriatic arthritis have reported Tietze’s Syndrome; psoriatic arthritis is a condition where arthritis is accompanied by red patches of inflamed skin. Other arthritis related diseases (i.e ankylosing spondylitis, reactive arthritis and Reiter’s disease) might also produce Tietze’s Syndrome.

Ulcerative colitis or Crohn’s disease.

Patients with inflammatory bowel disease such as ulcerative colitis and Crohn’s disease often report costochondritis and Tietze’s Syndrome.

Cancer

An Italian study led by R. Cocco found that several patients who were diagnosed with Tietze’s syndrome actually had tumors. The patients all had the classic signs of Tietze’s Syndrome—swelling of the costal cartilage, pain–and they were all treated with a standard treatment for the disease: anti-inflammatory drugs and an injection of cortisol. When symptoms didn’t improve, the patients sought answers: three of the cases were later found to have Hodgkin’s disease and one person had non-Hodgkin’s lymphoma. All four patients made a complete recovery after the cancer was diagnosed.

Heredity factors.

No one knows exactly what causes Tietze’s syndrome, but there could certainly be a hereditary factor. It could run in families—perhaps because of a genetic abnormality.

Radiation Therapy

If you have had radiation therapy to the chest or breast area, there is a chance you will experience Tietze’s Syndrome sometime down the road (it could be years after the therapy!).

Viruses

A virus caused my Tietze’s Syndrome; could it have caused yours? You can read more about my experience with the virus in this blog post.

Syphillis

Some studies have linked syphilis to outbreaks of Tietze’s Syndrome. You can find one of those reports here in the British Medical Journal.

Stress

There’s no definitive research to suggest that stress causes Tietze’s Syndrome, but it can worsen an underlying condition. For example, people with fibromyalgia should avoid stress, because it worsens the condition.

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References:

Cocco, R. et al. Lymphomas presenting as Tietze’s syndrome: a report of 4 clinical cases. Ann Ital Med Int. 1999 Apr-Jun;14(2):118-23.
Gill, G. Epidemic of Tietze’s Syndrome. Br Med J 1977;2:499 (20 August)
McCarty, D. & Koopman, W. Arthritis and allied conditions. NY, New York: Williams & Wilkins. 1993
Martino, G. et al. Tietze’s syndrome in the elderly: description of a case and review of the literature. Il Giornale di Chirurgia. 1994 Mar;15(3):119-23.
O’Neal, M. Complex strain injury involving an intercostal hematoma in a professional baseball player. Clin J Sport Med. 2008 Jul;18(4):372-3.      Pappalardo et. al, Reflexions on the Tietze syndrome. Clinica Terapeutica. 1995 Nov;146(11):675-82.
Russell, J. et. al. Elevated cerebrospinal fluid levels of substance p in patients with the fibromyalgia syndrome. Arthritis and Rheumatism. Volume 37 Issue 11, Pages 1593 – 1601. Published Online: 9 Dec 2005
Shiel, W. Costochondritis & Tietze Syndrome. Article posted on website medicinenet.com. Retrieved June 10, 2009 from http://www.medicinenet.com/costochondritis_and_tietze_syndrome/article.htm
Starlanyl, D. Reactive Hypoglycemia (RHG): FMS&MPS Complex Perpetuating Factor. Article posted on website Fibromyalgia Information. Retrieved June 9, 2009 from http://fibromyalgia.ncf.ca/dshypogl.htm.

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