Chest Pain in a 16-Year-Old Athlete the Week Before Championships
A 16-year-old boy presents with two weeks of intermittent sharp chest pain, worse with deep breathing and when lying flat, occasionally radiating to his left shoulder. He is a competitive swimmer training 2 hours daily, 6 days a week, and has a state qualifying meet in 8 days. He denies syncope, palpitations, or exertional pain. He had a viral upper respiratory illness three weeks ago with low-grade fever and myalgias that resolved. On exam: HR 88, BP 112/68, afebrile, oxygen saturation 98%. He has a soft systolic murmur at the left upper sternal border that does not radiate, and pain reproduced with palpation of the left costochondral junctions. Lungs are clear. He is anxious about being pulled from the meet and asks you to "just clear me."
1. What is your differential and how do you weigh the costochondral tenderness against the recent viral illness?
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The tenderness suggests costochondritis, but it does not exclude serious disease - up to a third of patients with pericarditis or other significant causes have chest wall tenderness as a distractor. The recent febrile viral illness with myalgias, positional pleuritic pain, and shoulder radiation raises pericarditis (or post-viral myopericarditis) as the leading concern to exclude. Other considerations: pneumonia, pulmonary embolism (unlikely but consider with the swimming/training history and any estrogen exposure), pneumothorax, and - given the murmur - structural heart disease or hypertrophic cardiomyopathy, though HCM pain is typically exertional.
The murmur is soft, non-radiating, and likely physiologic flow murmur of youth, but in an athlete with chest pain you cannot dismiss it on auscultation alone. Do not anchor on costochondritis because the exam "fits" and the patient wants clearance.
2. What testing do you order, and what do you tell him about the meet in 8 days?
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Obtain an ECG (looking for diffuse ST elevation, PR depression, or electrical alternans) and a chest radiograph, and send troponin and inflammatory markers (CRP, ESR). Echocardiogram if ECG or troponin is abnormal or if symptoms persist. If pericarditis is confirmed, first-line treatment is NSAIDs plus colchicine, with activity restriction.
Regarding the meet: competitive athletics should be avoided during acute myopericarditis and for a period afterward (commonly 3–6 months with full recovery and normalized testing), because exertion during myocardial inflammation risks arrhythmia and sudden death. Tell him plainly: this is not a decision about toughness, it is about a small but real risk of a fatal arrhythmia, and the timeline is measured in months, not days. If workup is normal, costochondritis can be managed with NSAIDs and activity as tolerated, but clearance comes after the workup, not before. Involve his parents and, with consent, his coach so the decision is not framed as the physician versus the athlete.