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JAMA Clinical Challenge

Episodic Abdominal and Chest Pain in a Young Adult

Computed tomography scan showing heterotopic ossification or chondrification (arrow) erroneously interpreted as xiphoid fracture.

Marcello Migliore, MD, PhD
Maria Signorelli, MD, PhD
A 22-year-old man has experienced intermittent severe chest and abdominal pain for a year. He stopped playing water polo because of recurrent severe abdominal pain in his right and left upper quadrant. He was evaluated for suspected pancreatitis, but all diagnostic results were unremarkable. A few weeks later he was admitted for acute chest pain, and again all diagnostic results were unremarkable. In 1 year the patient had 7 hospital admissions for abdominal or chest pain with no episodes of fever, chills, sweats, or cough. There is no history of trauma. The patient is currently treated with ketoprofen, oral morphine, and anxiolytic drugs. He spends almost all day in bed but is unable to sleep in a prone position and has pain in his throat. He has taken a leave of absence from college and reduced his social activities. The patient has received injections of cortisone and ketoprofen in the xiphoid area administered 10 days apart; however, pain persists. Physical examination is remarkable for considerable pain over the xiphoid on palpation. Slight pain is elicited on examination of the right second and third sternocostal cartilages. Chest computed tomography (CT) has been performed several times with interpretations ranging from osteochondritis to xiphoid fracture (Figure).

See the full article for an explanation and discussion.

Author Affiliations: Dr Migliore (mmiglior@unict.it) is affiliated with Thoracic Surgery, Department of Surgery, Policlinic Hospital, University of Catania, Catania, Italy; Dr Signorelli is affiliated with the Unit of Psychiatry, Policlinic Hospital, University of Catania, Catania, Italy.