Devil’s grip is an uncommon cause of chest pain. Also known as Bornholm disease, the grip of the phantom, dry pleurisy, and Sylvest disease, devil’s grip is caused by acute infection with coxsackievirus and less frequently by echovirus. This virus is transmitted via the fecal–oral route and is highly contagious, owing to a long period of viral shedding of 6 weeks. In some patients, their immune system limits the infection to a mild fever or flulike illness called summer fever . In others, a full-fledged infection with resultant pleurodynia and cough develops.
Devil’s grip has a seasonal variation in occurrence, with 90% of cases occurring in the summer and fall, with August being the peak month. No gender predilection is seen, but the disease occurs more commonly in young adults and occasionally in children. The pain is severe and described as sharp or pleuritic. The pain occurs in paroxysms that can last 30 minutes.
What are the Symptoms of Devils Grip
Physical examination of a patient with devil’s grip reveals a patient who appears acutely ill. Pallor and fever are invariably present, as is tachycardia. Patients may report of malaise, sore throat, and arthralgia, which may confuse the clinical picture. Examination of the chest wall reveals minimal physical findings, although a friction rub is sometimes present. During the paroxysms of pain, the patient suffering from devil’s grip attempts to splint or protect the affected area. Deep inspiration or movement of the chest wall markedly increases the pain of devil’s grip.
How is Devils Grip diagnosed?
Plain radiographs are indicated in all patients with pain thought to be the result of infection with coxsackievirus to rule out occult chest wall pathology, pulmonary tumors, pneumonia, or empyema. Ventilation/perfusion studies of the lungs are indicated if pulmonary embolism is being considered in the differential diagnosis. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, sedimentation rate, and throat cultures for Streptococcus spp. , may be indicated. Computed tomography (CT) scan of the thoracic contents is indicated if occult mass or empyema is suspected.
As is the case with costochondritis, costosternal joint pain, Tietze syndrome, and rib fractures, many patients with devil’s grip first seek medical attention because they believe they are having a heart attack. If the area innervated by the subcostal nerve is involved, patients may believe they have gallbladder disease. Statistically, children with devil’s grip have abdominal pain more often than do adults, and such pain may be attributed to appendicitis, leading to unnecessary surgery. In contradistinction to most other causes of pain involving the chest wall, which are musculoskeletal or neuropathic, the pain of devil’s grip is infectious. The constitutional symptoms associated with devil’s grip may lead the clinician to consider pneumonia, empyema, and occasionally pulmonary embolus as the most likely diagnosis.
As mentioned earlier, the pain of devil’s grip is often mistaken for pain of cardiac or gallbladder origin and can lead to visits to the emergency department and unnecessary cardiac and gastrointestinal workups. If trauma has occurred, devil’s grip may coexist with fractured ribs or fractures of the sternum itself, which can be missed on plain radiographs and may require radionucleotide bone scanning for proper identification. Tietze syndrome, which is painful enlargement of the upper costochondral cartilage associated with viral infection, can be confused with devil’s grip.
Neuropathic pain involving the chest wall also may be confused or coexist with costosternal syndrome. Examples of such neuropathic pain include diabetic polyneuropathies and acute herpes zoster involving the thoracic nerves. The possibility of diseases of the structures of the mediastinum is ever present, and such disease sometimes can be difficult to diagnose. Pathological processes that inflame the pleura, such as pulmonary embolus, infection, and tumor, also need to be considered.
Initial treatment of devil’s grip should include a combination of simple analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors. If these medications do not control the patient’s symptoms adequately, opioid analgesics may be added during the period of acute pain. Local application of heat and cold also may be beneficial to provide symptomatic relief of the pain of devil’s grip. The use of an elastic rib belt may help provide symptomatic relief in some patients.
For patients who do not respond to the aforementioned treatment modalities, the following injection technique using a local anesthetic and steroid may be a reasonable next step. The patient is placed in the prone position with the patient’s arms hanging loosely off the side of the cart. Alternatively, this block can be done with the patient in the sitting or lateral position. The rib to be blocked is identified by palpating its path at the posterior axillary line. The index and middle fingers are placed on the rib, bracketing the site of needle insertion. The skin is prepared with antiseptic solution. A 22-gauge, 11⁄2-inch needle is attached to a 12-mL syringe and is advanced perpendicular to the skin, aiming for the middle of the rib between the index and middle fingers. The needle should impinge on bone after being advanced approximately 3/4 inch. After bony contact is made, the needle is withdrawn into the subcutaneous tissues and the skin and subcutaneous tissues are retracted with the palpating fingers inferiorly; this allows the needle to be walked off the inferior margin of the rib.
As soon as bony contact is lost, the needle is slowly advanced approximately 2 mm deeper; this places the needle in proximity to the costal groove, which contains the intercostal nerve and the intercostal artery and vein. After careful aspiration reveals no blood or air, 3 to 5 mL of 1% preservative-free lidocaine is injected. If the pain has an inflammatory component, the local anesthetic is combined with 80 mg of methylprednisolone and is injected in incremental doses. Subsequent daily nerve blocks are done in a similar manner, substituting 40 mg of methylprednisolone for the initial 80-mg dose. Because of the overlapping innervation of the chest and upper abdominal wall, the intercostal nerves above and below the nerve suspected of subserving the painful condition need to be blocked. Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.
The major problem in the care of patients believed to have devil’s grip is the failure to identify potentially serious pathological conditions of the thorax or upper abdomen. Given the proximity of the pleural space, pneumothorax after intercostal nerve block is a distinct possibility. The incidence of the complication is less than 1%, but it occurs with greater frequency in patients with chronic obstructive pulmonary disease.
Because of the proximity to the intercostal nerve and artery, the clinician should calculate carefully the total milligram dosage of local anesthetic administered, because vascular uptake by these vessels is high. Although uncommon, infection is an ever-present possibility, especially in an immunocompromised patient with cancer. Early detection of infection is crucial to avoid potentially life-threatening sequelae.
Devil’s grip is an uncommon cause of chest pain that is frequently misdiagnosed.
Correct diagnosis is necessary to treat this painful condition properly and to avoid overlooking serious intrathoracic or intra abdominal pathology. Intercostal nerve block is a simple technique that can produce dramatic relief for patients with devil’s grip.
As mentioned, the proximity of the intercostal nerve to the pleural space makes careful attention to technique mandatory.