The most common cause of musculoskeletal chest pain is costochondritis, with an incidence of up to 30 percent of all musculoskeletal chest pains,103'104 with inflammation of the costal cartilages and up to 42 percent of patients with recurrent costochondritis complaining of widespread pain.103 In a number of patients the chest pain still prevails once the clinical signs of costochondritis have subsided. The incidence of costochondritis has risen steadily in the last few years because of an increase in the abuse of intravenous recreational drugs, mainly heroin.105,106107 Other conditions that predispose to costochondritis are diabetes, sepsis, following cardiothoracic surgery and medications. There have been an increasing number of case reports of patients with costochondritis secondary to Pseudomonas aeruginosa, Candida albicans,106 Salmonella pertusis,108 and Escherichia coli.109

The main symptom is pain or tenderness in the front of the chest that is normally sharp, exacerbated by pressure and movement of the chest wall. It can affect more than one costal cartilage. Tietze's syndrome is an entity similar to costochondritis. The main difference is the presence of swelling of the affected area with Tietze's syndrome that does not exist in costochondritis.

Treatments include conservative and interventional, and anti-inflammatory treatment both with steroids and nonsteroids has been described. Sulfasalazine (sulphaza-lazine) shows some evidence of being helpful in long-term treatment.110[V] Interventional treatments that have been reported in four "illustrative" cases and include debri-dement, rib excision, chest wall en-bloc excision, and flap reconstructions111 have been suggested in advanced cases. Most patients will achieve spontaneous resolution within a year,112 so surgery must be regarded with considerable suspicion.

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