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Chest pain hurts to touch
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Chest pain hurts to touch

Doctor,
I'm a 25 year old male, no history of smoking.  
My question is about chest pain but let me give you some background information first.  For the last six months I have had a chronic cough that won't go away (as well as some fatigue and enlarged non-tender lymph nodes in the neck).   The chronic cough is sometimes productive and sometimes just dry.  It goes back and forth.   In May, I was diagnosed with mono.  I don't know if the cough is actually from the mono or something unrelated - my doctor has never really told me.  Well, the cough and lymph nodes are still sticking around.  So the doctor sent me for a CT scan of the neck and a chest xray.  Both tests came up clean - other than the enlarged lymph nodes.  Over the last few days, I've noticed I have some chest pain.  But it's in my lower chest.  Maybe an inch or two below my right nipple.  It's not a constant ache, though.  I can feel a little bit of a sharp tightness in that spot when I twist and turn sometimes and when I take a deep breathe.  Also, if I press on the thick part of my chest to the right of the xiphoid process, it feels noticeably sensitive to the pressure.  The pain isn't the ribcage itself, but beneath it.  When I press on the left of the xiphoid process, there's no pain, though.  

Here are some questions...
1)  Does this sound like something cancer?  If there was a tumor in or around my ribcage, would it feel like this?  Would my chest x ray have picked it up?
2)  My symptoms have also had me concerned about lymphoma.  Would a chest x-ray pick up anything suspicious lymphoma in my chest like more enlarged lymph nodes?
3)  Does this sound like it could be liver-related?
4)  Finally, how concerned should I be?  How should I proceed?  My ENT doesn't think we need to biopsy the lymph nodes in my neck.  Should I just wait for the chest pain/chronic cough to go away?
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242587_tn?1355427710
Let me answer your questions, in order.  

1. No this does not “sound like something cancer.”  It would be rare for a tumor in or around your ribcage to cause pain, especially in the absence of abnormalities on the chest X-ray and CT Scan of your chest.  That the pain worsens with direct pressure is most suggestive of musculoskeletal pain, unrelated to your cough and enlarged cervical lymph nodes.
2. Lymphoma is a realistic concern but the lymph node enlargement limited to the cervical nodes (by CT Scans), the lack of enlargement of these nodes over the past six months and the (presumably) positive testing for Mono strongly favor that diagnosis.
3. Nothing you have mentioned suggests liver disease but that is a question that could be quickly answered by a biochemistry “liver panel.”
4. You should be mildly concerned.  The negative CT Scans are very reassuring in terms of excluding lymphoma and other such diseases.  The ENT’s reluctance to biopsy the enlarged cervical nodes is reasonable, given their stability in number and size.  It would be wise, however, for your physicians to conduct periodic examinations, every two-four months, with special attention to the development of additional enlarged lymph nodes and/or enlargement of your liver or spleen.  While I very much doubt that the lymph nodes are anything more than those associated with mononucleosis, you might for peace of mind request a second opinion from an oncologist (cancer specialist).   Given the long period over which your symptoms have persisted, a second opinion might be helpful, in any event.

The cough, occurring with enlarged cervical nodes is puzzling. Cough, especially in the absence of tonsillar enlargement, is unusual with mono. Pressure on the trachea or major bronchial tubes, from enlarged nodes, can cause cough, but you stated that none were evident.  You might, however, want to request a review of your CT Scan by the radiologist, with this concern in mind.

It is possible that the agent that caused enlargement of the cervical nodes might also cause airway inflammation, leading to what is called cough variant asthma.  You may wish to discuss the possibility of asthma with your doctor, for if this is cough variant asthma, treatment of the asthma could result in relief of your cough.

If the lymph node enlargement should persist for another 6-12 weeks, or show any signs of further enlargement, your doctors might want to reconsider the question of a lymph node biopsy.

Good luck
3 Comments
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Avatar_n_tn
I forgot to mention that I tried taking tylenol the other day and it seemed to main the chest pain go away temporarily.
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Avatar_n_tn
Sorry - it took a couple days to notice you had responded.

One quick question if you don't mind... You said that the cough is puzzling without tonsillar enlargement.  Well, interestingly enough, this whole saga started in January with a severe case of tonsillitis on the right side.  It was severely swollen, but didnt hurt, for several weeks, but eventually went away.  Shortly after, the cough, which has never gone away, started.  

Could there be any connection between the tonsil enlargement and the cough, like I believe you may have alluded to?  
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