A TEENAGER WITH CHEST PAIN

The most likely diagnosis in this case is idiopathic chest pain. This is one of the commonest causes of chest pain in children. Psychological chest pain, which may be a replication of the pain his grandfather used to have, and may be secondary to various stresses such as bullying, is a further possibility. Costochondritis is due to inflammation of the cartilage that connects the inner end of each rib with the sternum. There may be tenderness on palpation of the cartilage in the anterior chest wall and the pain may be worse on movement or coughing. The cause is unknown and the condition is self-limiting. The lack of respiratory symptoms and signs with the normal PEFR would go against a respiratory cause. PEFR is related to height, and charts with normal values exist. Children have to be 5 or more years of age in order to perform this test in an effective and consistent manner, and normally the best reading out of three is obtained. Pneumonia with pleurisy is a common cause of chest pain that is typically worse on inspiration. In the case of a pneumothorax, the pain is sudden and associated with shortness of breath. A severe cough from whatever cause can lead to musculoskeletal chest pain. The lack of gastrointestinal symptoms such as vomiting would go against gastrooesophageal reflux. Cardiac disease is a rare cause of chest pain in children. The palpitations described are probably secondary to tachycardia during exercise.

Differential diagnosis of chest pain

• Trauma, e.g. fractured rib

• Exercise, e.g. overuse injury

• Idiopathic

• Psychological, e.g. anxiety

• Costochondritis

• Pneumonia with pleural involvement

• Asthma

• Severe cough

• Pneumothorax

• Reflux oesophagitis

• Sickle cell disease with chest crisis and/or pneumonia

• Rare: pericarditis, angina, e.g. from severe aortic stenosis, osteomyelitis, tumour

The patient and his family should be reassured. Ibuprofen could be used on an as necessary basis for its analgesic and anti-inflammatory properties for the more prolonged bouts of pain. The child should be reviewed in about 2 months to monitor progress.

KEY POINTS

• Chest pain in children is often idiopathic, psychological or musculoskeletal in origin.

• Pulmonary causes are a further common cause of chest pain.

• Cardiac disease is a rare cause of chest pain in children.

• A chest X-ray and ECG should be done to rule out significant pathology.