Chronic pain of undetermined origin
Short Summary

67-year-old male suffering a constant pain at the bottom of the lower left rib cage for the last two years. The pain is described as not being extreme nor affected by breathing; it is dull and always present. Various imaging scans were unremarkable although diffuse degenerative disk spinal abnormalities were noted.

Patient's Questions

1. What could be the cause of the patient’s pain?
2. Are there any other tests that the patient could have?
3. Is there a specific centre that the patient could consult?
4. What therapy could the patient try?
 

Medical Background

Age: 67, Sex:M
Diagnosis:Chronic pain of undetermined origin
 
Case history and clinical report:
Male patient, 67 years of age, in reasonably good health.Ex-smoker of 20 cigarettes a day.The patient was diagnosed with dilative cardiomyopathy, which was treated with Cardioaspirin and two unspecified medications.
Following abdominalgia, the patient had a pancolonoscopy that showed mild, non-complicated, diffuse diverticulitis and the presence of two polyps. These were removed during the examination; one was in the descending colon (histology: villoglandular adenoma with low grade dysplasia) and the other was in the rectum (histology:  hyperplastic polyp with surface erosion).
The patient began experiencing a localized stabbing pain in the area of his left last rib.This pain is unaffected by breathing, but sometimes changes with posture and is slightly worse after meals.The pain is now dull and always present, but is not very debilitating.The patient had a series of tests.
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X-ray of chest and hemithorax:No pleuropulmonary lesion foci.Slight reinforcement of broncovascular trees in the inferior hiloperihilar region due to known bronchial problems.Mediastinum in place and not enlarged.Medium-volume hilii.Heart within normal limits.Initial lengthening and opacification of aortic arch.No evident current structural bone lesion foci or trauma of costal skeletal segments in left hemithorax.In some x-rays there is a small round opaque area with distinct edges in the medial anterior arch of the sixth rib, likely indicating an area of compact bone or possibly an osteoma. However, given the clinical findings, it merits further radiological follow-up in the near future and, subject to clinical opinion, further diagnostic testing by means of scintigraphy.
Total body bone scintigraphy:“no increase in osteoblastic turnover of the medial anterior length of the left sixth rib, which was the location of a round opaque area in an x-ray .”
The x-ray did not show significant changes compared to previous findings.
 
The results of the muscle and tendon echo-tomography of the left hemithorax were within normal limits.
The patient also had visited a neurologist, given the suspicion that the pain might be of neuropathic origin. However, based on an examination of the patient, the neurologist tended to exclude this possibility, although he prescribed Pregabalin (75 mg X2, which was never taken), a dorsal and thoracic MRI of the lower thorax and last vertebrae (D5-D12), anti-HSV and anti-HZV antibody dose.
Antivaricella IgG antibodies in serum 911.30MlU/ml (>195=positive); antivaricella IgM antibodies in serum <0.9 (negative).
 
Chest MRI and dorsal spine MRI:
No significant asymmetries of rib cage.No observed expansion abnormalities of left hemithorax in the painful area reported by patient.No muscle abnormalities.Metamers in the dorsal spine region are correctly aligned in the sagittal plane and there are no bone lesions of current pathological significance.Presence of diffuse arthritic abnormalities, which are more significant in the inferior dorsal side with marginal somatic border osteophytosis.In terms of discs, there are mild degenerative abnormalities mainly characterized by dehydration of the pulpy nuclei.No images that can be associated with herniated discs or significant protrusions.The intrinsic signal of the spinal medulla was maintained in both captures.
 
Chest CAT scan:Assessment of the mediastinum showed the presence of aortic and coronary calcifications, as well as small reactive lymph nodes in the paratracheal region.   Cholecyst calculus was observed.The pulmonary parenchyma is preserved.No pleural or pericardial effusion.Skeletal assessment showed that calcium level was maintained, with no diffuse medio-dorsal spondylosis.Presence of diffuse chondral calcifications.A small sclerotic area was observed in the medial arch of the sixth rib.In addition, dysmorphism was observed in the third anterior rib and costochondral joint of the ninth rib, likely attributable to the stabilized effects of trauma.Lastly, slight linear calcification was observed in the soft tissue of the anterior muscle wall at the apex of the eleventh rib.
Anti-HSV1 antibodies present in serum (IGG); no HSV2; HZV (IGG) present.
Tests for fecal occult blood were positive in 2 out of 3 samples.
In the last two years, the pain has become slightly worse.The patient has never taken pain killers and is able to sleep at night.

 

Expert's Opinion

Pain description allows a wide differential of diagnoses. Due to the fact that symptoms are stable and extensive study was unremarkable, neuropathic pain due to thorathic facet involvement is one possibility.  Pain arising from the abdominal wall or viscera is another possibility. 
I think that further studies or treatment are indicated only if symptomatic relief is warranted.
 
I would recommend revising studies regarding facet arthropathy. Facet block may be considered depending on findings.
 
Para vertebrae or inter-costal diagnostic blocks followed by therapeutic blocks may be considered. Alternative systemic analgesic and anti-neuropathic medications may also be considered.

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