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Chest pain Chest pain can arise from the chest wall, parietal pleura, mediastinal structures, tracheobronchial tree, pericardium, oesophagus and subdiaphragmatic organs (liver and gallbladder).Herpes zoster infection (shingles) may start with superficial itch or burning pain in a thoracic dermatome, followed by the appearance of a vesicular rash (a 'belt of roses from hell'). Costochondritis (called Tietze's syndrome when costochondral swelling is present) is idiopathic inflammation of the costochondral cartilages adjoining the sternum, with acute localised pain and tenderness.Exacerbating or relieving factors: worsening with cough or deep breaths suggests pleural disease.

Chest pain
Chest pain can arise from the chest wall, parietal pleura, mediastinal structures, tracheobronchial tree, pericardium, oesophagus and subdiaphragmatic organs (liver and gallbladder). Pain
does not originate in the lung parenchyma or visceral pleura, as
they have only an autonomic nerve supply.
Establish:
• Site and severity.
• Character: sharp suggests pleural pain.
• Onset: gradual or rapid?
Exacerbating or relieving factors: worsening with cough or
deep breaths suggests pleural disease.
• Associated symptoms: breathlessness, fever and cough
suggest an infective cause.
A large pulmonary embolus can cause angina-like chest pain
(p. 85), due to increase of right ventricular work together with
reduced coronary oxygen delivery caused by hypotension and
hypoxaemia, resulting in right ventricular ischaemia.
Pleuritic pain is worse on inspiration and coughing, and is
usually described as sharp, stabbing or knife-like. It is usually
sited away from the midline and may be localised or affect a wide
area of chest wall. Disease causes parietal pleural pain in several
ways:
• pneumonia and pulmonary infarcts: either direct pleural
inflammation or adhesions with pleural traction on respiratory
movement
• pneumothorax: mechanical distortion of pleura with lung
collapse
• lung cancer: pleural distortion by infiltration, although constant pain is more typical
Musculoskeletal chest pain is common and may occur with
chest trauma, forceful coughing or connective tissue disease.
The chest is characteristically tender to palpation, and the pain
can be reproduced by respiratory movements and/or movement
of the spine or shoulder muscles. There may be associated soft
tissue injury or rib fractures. A detailed history of events preceding the onset is vital, as injury is easily overlooked.
Two other uncommon conditions can cause acute chest pain.
Bornholm disease is an infection with an enterovirus (Coxsackie
B). This causes acute but self-limiting inflammation of intercostal
muscles, with episodes of severe unilateral intercostal myalgia
lasting a few days. Costochondritis (called Tietze’s syndrome
when costochondral swelling is present) is idiopathic inflammation of the costochondral cartilages adjoining the sternum, with
acute localised pain and tenderness. The pain is eased by simple
analgesia and settles spontaneously in both conditions.
Herpes zoster infection (shingles) may start with superficial itch
or burning pain in a thoracic dermatome, followed by the
appearance of a vesicular rash (a ‘belt of roses from hell’). Pain
and altered sensation may persist long after the rash has
resolved, often with scarring in the affected dermatome.
Burning retrosternal pain may indicate oesophagitis but also
occurs with myocardial ischaemia. Worsening of oesophageal
discomfort after eating or relief after antacids helps to distinguish
it from cardiac pain.
Cardiac pain is described on page 45.
Central, constant, progressive, non-pleuritic chest pain may
represent mediastinal disease, particularly malignancy. Similarly,
chest wall pain (without trauma) that is constant, progressive and
non-pleuritic suggests chest wall invasion by malignancy. Sleep
disturbance is a feature of such malignant pains.