Miscellaneous Causes Pain Related to Underlying Diseases

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1. Sickle cell disease. Children with vasoocclusive crisis may have pain that localizes to the chest or produces acute chest syndrome.

2. Marfan syndrome. May result in chest pain and fatal dissection of an abdominal aortic aneurysm.

3. Herpes zoster infection. Shingles may produce severe chest pain that precedes the classic vesicular rash by several days or occurs simultaneously.

4. Coxsackievirus infection. This common viral infection may lead, rarely, to pleurodynia with paroxysms of sharp pain in chest or abdomen ("devil's grip").

5. Breast tenderness. Teenagers or preteens may complain of chest pain from physiologic changes of puberty or from early changes of pregnancy.

6. Thoracic tumor. Hodgkin disease or non-Hodgkin lymphoma may present with chest pain but undoubtedly there will be other signs and symptoms of disease.

7. Precordial catch syndrome. Texidor twinge or "stitch in the side" is thought to cause unilateral chest pain that lasts a few seconds or minutes and is associated with bending or a slouched posture. It is believed the pain arises from parietal pleura or from pressure on an intercostal nerve, but etiology is unclear. Straightening up and taking shallow breaths or one deep breath relieves the pain, which may recur often or remain absent for months.

8. Slipping rib syndrome. This is a rare "sprain disorder" caused by trauma to costal cartilages of the 8th, 9th, and 10th ribs that do not attach to the sternum. Children with slipping rib syndrome complain of pain under the ribs or in upper abdominal quadrants. They also hear a clicking or popping sound when lifting objects, flexing the trunk, or even with walking. It is believed that the pain is caused by one of the ribs hooking under the rib above and irritating intercostal nerves. Pain can be duplicated and syndrome confirmed by performing the "hooking maneuver," whereby the affected rib margin is grasped and then pulled anteriorly. Surgery is thought to be the only definitive management, although most patients are treated satisfactorily with nonopioid analgesics.

9. Idiopathic chest pain. Diagnosed in 20-45% of patients with pediatric chest pain, when no other diagnosis can be determined with certainty.

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