A 50-year-old Lebanese man presented to our hospital for ongoing chest pain of 2.5 months’ duration felt upon coughing, sneezing, or laughing. The patient had experienced a mild episode of self-limited bronchitis 3 months ago for 1 week, after which he developed constant, dry, nonproductive cough and chest pain. In the patient’s past medical history, chest trauma, chronic diseases, and allergies to any medication were absent. With regard to his social and professional history, the patient is a wealthy businessman who works in Saudi Arabia. He does not consume alcohol at all. He does not take any drug for any chronic or acute disease. He has no history of cancer or similar condition in his family. His physical examination revealed no remarkable findings except for tenderness upon palpation of the chest, mainly in the midaxillary line. No crackle, wheeze, or barrel chest was present. His pulse was slightly increased from baseline, reaching 86 beats/minute due to pain. His blood pressure was 130/85 mmHg. His body temperature was normal at 36.2 °C. A complete blood count and a metabolic panel were ordered to rule out any anemia or plasma cell dyscrasia, and the results of these were normal. Blood tests ordered and performed were the following: prostate-specific antigen, thyroid function test (thyroid-stimulating hormone, T3, and T4), carcinoembryonic antigen, parathyroid hormone, liver function tests, and serum creatinine. His blood tests showed no abnormal findings except for a low vitamin D level. In addition, his erythrocyte sedimentation rate and C-reactive protein were found to be elevated (Table
1). Additional workup was needed. Abdominopelvic, neck, and chest computed tomographic (CT) scans (Fig.
1) were ordered first to rule out any metastatic, prostate, or focal cancers. His lung parenchyma and bronchial wall thickness were normal. Following the CT scans, an x-ray showed fractures of the lateral right sides of the sixth and seventh ribs. Because the patient was a smoker, a bone scintigraphy scan (Fig.
2) was performed in order to rule out any metastatic disease. Several foci of bone hyperfixation were identified by scintigraphy. The findings were distributed as follows: (1) anterior arch of the ninth left rib; (2) anterior arches of the fifth, sixth, and seventh right ribs creating aligned foci; and (3) double fractures in the anterior bow of the fifth right rib. Other bone abnormalities were insignificant at this stage. No pulmonary function tests were done, because the patient did not show any signs of chronic obstructive pulmonary disease. Finally, his osteodensitometry results were normal.
The patient was managed with antitussives and nonsteroidal anti-inflammatory drugs, with which he slowly improved. For his chest pain, the patient was administered simple analgesia consisting of codeine phosphate and acetaminophen, with tramadol if needed, and the patient did not need it. Three months later, the patient completely recovered. At his 6-month follow-up, the patient was symptom-free with no chest pain and with a complete normal examination with no pain in his ribs. At his 9-month of follow-up, the patient was completely well, so no further investigations were done.