Chest pain: Virtual or pathological?


Dear Editor,

Chest pain in children is a major concern for parents due to its association with heart disease and death. We report an interesting case of a 15-year-old male with severe chest and arm pain associated with intensive electronic game use.

A previously well young man presented with 3 days of chest pain with onset at rest. It was localised to a small area above the left nipple, varying in intensity from a background ache to a severe, sharp pain associated with dyspnoea. He also reported a constant ache on the medial aspect of his left elbow. There were no recent fevers or coryzal symptoms. The episode occurred during a holiday period when the patient had spent 10–15 h/day playing Xbox games over 2 weeks. The patient was well looking with normal vital signs. Cardiac examination was normal, and there was no tenderness on palpation of the chest wall or arms. There was no weakness, neurological abnormalities, or calf tenderness.

Serial electrocardiographs demonstrated normal sinus rhythm with no evidence of ischaemic changes, and there were no abnormalities detected on chest radiograph or echocardiogram. Initial creatine kinase (CK) was elevated at 814 IU/L (normal range 1–370 IU/L), and on day 2 (553 IU/L) and day 3 (389 IU/L). Other investigations including serial troponins, lactate dehydrogenase, acute phase reactants, electrolytes, thyroid, liver and renal function, full ward test, full blood count, and subsequent exercise stress test were normal. The patient's symptoms resolved with intravenous fluids, ibuprofen, paracetamol, and rest, and he was discharged home on day 4.

Cardiac events are extremely rare in young people, and chest pain is commonly musculoskeletal. Generally myalgia or myositis with CK elevation has infectious or inflammatory aetiology.[1] The CK elevation in this case was consistent with a muscular response to exercise.[2]

Rhabdomyolysis as a side effect of the digital age was first reported in 1995 and was linked with keyboard overuse following a viral illness.[3] A subsequent paper from South Korea in 2007 was the first to link rhabdomyolysis and computer gaming in a patient who had played computer games for 3 days without rest or fluid intake.[4] Although conventional hand-controlled electronic games are generally not regarded as ‘active’,[5] it is reasonable to conclude that when played excessively, prolonged or repetitive activation of the muscles of the chest and upper limbs can be sufficient to induce muscle injury.

Currently, there are no published cases linking computer gaming and modest elevations in CK. This diagnosis of localised myalgia due to excessive computer gaming provides a relevant differential diagnosis to consider in young people with undifferentiated chest pain.