It all started with a shallow cough (upper chest/throat) two weeks ago. He was sent hom from school and complained about trouble breathing ("it's hard to breath"). Later he got a chest x-ray and it was clear (no signs of trauma or pnemonia). Cough subsides, but new symptoms of stridor (on the intake) and chest pain develop near his sternum on the left side, but also radiating all over his left rib cage. It is tendor to the touch and very tendor if pressed. He goes to the hospital and they run many tests. All vitals are fine (no fever, BP good, EKG fine). No sign of infection in blood test. Oxygen levels fine. Chest pain still heavy and pain killers not taking off the edge. They decide to do a CT scan - it's clear. Pulmenary specialist sees nothing wrong with lungs. He could not successfully complete a pulmenary function test (his breaths were not consistent enough). New blood test show slightly elevated liver enzymes compared to 3 days prior (but still in normal range). Ultrasound of liver fine. Doctors notice that he has some level of "distractable pain". He was later discharged from the hospital since all of the tests seemed to turn nothing up.
More recenlty he has started apparent vocal chord disfunction attacks (which are scary because he seriously can't seem to get breath). These alternate with the severe chest pain in the same area described above. He also has an added symptom that his voice is now hoarse and he has difficulty swallowing (possibly due to all of this clinching and vocalizing of his discomfort). We wonder how much all of this is further triggered by anxiety and stress of the situation. Although it is tough to get him to sleep, when he's asleep, he does sleep through the night.
One thought is costocondritus, but there are several other symptoms that may not fit and the pain is very high. We need to figure out what is going on with our 9-year-old boy and how to address it. Please help.
This is a difficult diagnostic situation. The normal CT scan is reassuring but, given the persistence of symptoms, it would not be unreasonable to request that the Scan be reviewed with special attention to the mediastinum (the anatomic area between the lungs), trachea, larynx and esophagus. The details you have provided do indeed suggest that your son’s illness includes an element of laryngeal (including vocal cords) disease/dysfunction. Such dysfunction can be functional, as for example the classic, often idiopathic vocal cord dysfunction (VCD), or secondary to other diseases including, gastro-esophageal reflux (GERD), benign polyps or tumors, and infectious disease, especially viral infections – see below.) In this regard there is a condition associated with GERD, called misdirected swallowing associated with hiatal hernia. This would be consistent with both the hoarseness (secondary to aspiration) and the difficulty swallowing your son has experienced. However, these conditions are seldom associated with chest pain and chest wall tenderness, especially of the severity you describe.
If he remains symptomatic, his doctors might want to consider direct (fiberoptic) examination of his larynx and esophagus, along with a swallowing study. If swallowing has continued to be difficult for him, consultation with a GI (gastroenterologist) should also be considered,
An unlikely, but more intriguing diagnosis is a viral (Coxsackie or Entero-virus) disease called Pleurodynia, characterized by spasmodic, paroxysmal pain (often referred to as, “the devil’s grip”. Most common in adults, it can occur in children. This is an acute infection of skeletal muscle of (often of the chest wall) usually, but not always associated with fever. The pain may be either in the chest wall or abdomen. The same pain, tenderness, can often be elicited by direct pressure on the effected muscles.
You state: “More recently he has started apparent vocal chord dysfunction attacks (which are scary because he seriously can't seem to get breath). These alternate with the severe chest pain in the same area described above. He also has an added symptom that his voice is now hoarse and he has difficulty swallowing”
This makes me wonder if the chest pain might be secondary to esophageal spasm, associated with GERD leading to aspiration and vocal cord spasm. Yet another reason why direct examination of larynx and esophagus could be revealing. Finally, another diagnosis that could link the shortness of breath, stridor and difficulty swallowing could be disease of the epiglottis, either infectious or by a benign tumor, the latter most likely to occur without fever.
To summarize, I recommend consideration of direct examination of both larynx and esophagus as most of your son’s symptoms are suspicious for disease in one or both of these areas.
I have reason to believe that your son has laryngopharyngeal reflux and not GERD you should go see an ear, nose, and throat doctor. This is a fairly common disorder that is difficult for a general practice doctor or an allergy doctor to diagnose.
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