What is the likely diagnosis and management for a patient with sharp pleuritic chest pain below the left nipple radiating to the back, a normal electrocardiogram, and unchanged calcified infrahilar nodes on chest X‑ray?

Costochondritis: Definition and Clinical Presentation

Costochondritis is an inflammatory condition of the costochondral junctions or chondrosternal joints of the anterior chest wall that presents with reproducible chest wall tenderness on palpation and is a diagnosis of exclusion after ruling out serious cardiac and pulmonary causes. 1

What Costochondritis Is

Costochondritis is inflammation at the costochondral or costosternal junctions, typically affecting the third through seventh ribs, presenting as localized chest pain that is reproducible with palpation over the affected costal cartilages. 1, 2

The condition is usually self-limited and benign, with symptoms typically resolving within a couple of weeks in most cases. 3, 1

Key Clinical Features

The hallmark diagnostic feature is reproducible pain with direct palpation over the costochondral junctions, distinguishing it from cardiac causes of chest pain. 1

The pain characteristics include:

• Sharp, localized chest wall pain that can be pinpointed with one finger over the affected costochondral junction 4
• Pain reproduced with movement or palpation of the chest wall 4
• Pain that may worsen with deep breathing, coughing, or upper body movements 1

Critical Distinction from Cardiac Pain

While costochondritis pain is reproducible on palpation, this finding does NOT completely exclude acute coronary syndrome—7% of patients with chest pain reproducible on palpation were ultimately diagnosed with ACS. 4

Features that suggest costochondritis rather than cardiac ischemia include:

• Pain localized at the tip of one finger, particularly over a costochondral junction 4
• Pain reproduced with movement or palpation of the chest wall or arms 4
• Pleuritic quality (sharp or knifelike pain brought on by respiratory movements) 4

However, coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation, so cardiac evaluation remains essential in appropriate populations. 1

Diagnostic Approach Based on Patient Age and Risk

For children, adolescents, and young adults: History and physical examination documenting reproducible pain by palpation over the costal cartilages is usually sufficient for diagnosis. 1

For patients older than 35 years, those with cardiac risk factors, or any patient with cardiopulmonary symptoms: Obtain electrocardiogram and consider chest radiograph before diagnosing costochondritis. 1

Further cardiac testing should be pursued if clinically indicated by age or cardiac risk status, as costochondritis is a diagnosis of exclusion. 1

Management

First-line treatment consists of acetaminophen or NSAIDs (where safe and appropriate), activity modification to avoid chest muscle overuse, and patient reassurance. 1

For persistent cases (atypical costochondritis lasting beyond the typical 2-week resolution period):

• Stretching exercises show progressive significant improvement compared to standard treatment alone (p<0.001) 2
• Osteopathic manipulation techniques and instrument-assisted soft tissue mobilization may provide benefit 3
• Local heat application can be considered 2

Important Caveats

Atypical costochondritis refers to cases that do not self-resolve within the typical timeframe and is associated with high medical expenses and psychological burden on patients. 3

Infectious costochondritis is a rare but serious condition that develops from direct spread of infection (postoperative wounds, adjacent foci, or hematogenous spread) and requires antibiotic therapy and potentially surgical debridement—this must be distinguished from typical inflammatory costochondritis. 5, 6

Red flags requiring further investigation include:

• Fever or systemic symptoms suggesting infection 5, 6
• Purulent drainage or skin changes 5
• Diabetes or immunocompromised state (higher risk for infectious causes) 5, 6
• Persistent symptoms despite appropriate conservative treatment 3

Application to the Clinical Scenario

For a patient with sharp pleuritic chest pain below the left nipple radiating to the back, normal ECG, and unchanged calcified infrahilar nodes on chest X-ray:

The likely diagnosis is costochondritis if pain is reproducible on palpation of the affected costochondral junction. 1

The pleuritic quality and sharp nature are consistent with costochondritis, and the normal ECG reduces (but does not eliminate) concern for acute coronary syndrome. 4, 1

The unchanged calcified infrahilar nodes suggest chronic findings (likely old granulomatous disease) rather than acute pathology. 4

Management should include NSAIDs or acetaminophen, activity modification, and reassurance, with consideration of stretching exercises if symptoms persist beyond 2 weeks. 1, 2

However, given the radiation to the back, maintain clinical vigilance for other causes including pulmonary embolism (though less likely with normal oxygenation if present), pericarditis, or musculoskeletal pain from thoracic spine pathology. 4, 7, 8