Mondor's Disease of Chest Wall: A Case Report

Background: Mondor's disease (MD) is a rare benign and self-limited entity characterized by supercial thrombophlebitis of a vein in special regions. It may be secondary to trauma, malignancy, surgery, excessive physical activity or hyperviscosity. Diagnosis of MD is often based on history and physical examination. Case presentation: Here we present a rare case of Mondor's disease of chest wall with a pain and subcutaneous cord-like induration of right lateral chest. Ultrasonography revealed a supercial venous thrombosis of right thoracoepigastric vein. After treatment of aspirin for 2 weeks, chest pain was obviously relieved, and the lesion completely resolved approximately 6 weeks after presentation. Conclusions: Mondor’s disease could spontaneously resolved after several weeks and excessive medical intervention should be avoided.


Background
Mondor's disease tends to occur in middle-age women. Chest pain is the most common reason for seeking medical attention. We present a rare case of Mondor's disease of right lateral chest wall. The aim is to further understand this kind of disease and to characterize the its pathogenesis, diagnosis, treatment and prognosis. When we encounter this disease in clinical work, pain relief and observation are the rst choices to avoid excessive medical intervention and unnecessary medical damages.

Case Presentation
A 45-year-old female was admitted to outpatient with a week history of moderate pain and linear induration on his right lateral chest after overextending her right arm. She denied any other symptoms and history of fever, trauma or nipple discharge. But she had a history of strenuous exercise of the upper limbs for 3 years and chronic viral hepatitis B for 10 years without antiviral drug treatment. Physical examination revealed a tender subcutaneous cord beginning from the right anterior axillary fold to the right costal arch with obvious tenderness along the whole length. The appearance of the cord become clear when lifting his right arm above the head (Fig. 1). Doppler ultrasonography showed a noncompressible right thoracoepigastric vein containing abnormal echogenic material, which was consistent with super cial venous thrombosis (Fig. 2). Chest computed tomography (CT) didn't reveal any evidence of an underlying mass compressing the veins. There was no evidence of associated deep venous thrombosis. She was treated with aspirin (non-steroidal anti-in ammatory drugs, NSAIDs) for 2 weeks, and chest pain was obviously relieved. The lesion completely resolved approximately 6 weeks after presentation and the patient remains without recurrence had during 2 year follow-up.
Mondor's disease is a rare and self-limited disease, which was rst reported by Fage in 1870 [1]. Due to its rarity, this disease is poorly understood. The reported sites are mainly in the anterior thoracic region, and few cases in the axillary region or penis.Studies reported the incidence of Mondor's disease ranged from 0.07-0.96% [2]. Mondor's disease always begins with a sudden onset of pain and a visible tenderness subcutaneous cord [3,4]. The most common symptom is pain and local tenderness, and the most common sites are mammary region and the anterolateral wall of thorax [2,5,6]. Moreover, the affected veins include thoracic lateral vein, superior epigastric vein and the thoracoepigastric vein [7,8]. The speci c pathogenesis of Mondor's disease is still unclear. Some reports have suggested that it may be associated with local trauma, surgery, infections, excessive exercise of the upper limbs [7,9], cancer or hypercoagulability. A research revealed that MD was associated with primary or metastatic breast cancer [10], but it remains unproven. In view of this patient's history, chronic hepatitis B, as well as excessive exercise of the upper limbs, may be two important causes for MD.
The main pathogenesis of MD is con rmed to be thrombophlebitis, and few is lymphangitis [11]. There are often two stages in the development of Mondor's disease, namely acute in ammatory cell in ltration accompanied by thrombosis in the veins and connective tissue proliferation in the veins resulting in the formation of a hard cord [3,4,11]. The diagnosis of MD is usually based on history, physical examination and ultrasound ndings. Robert et al.
[6]found a high prevalence of active cancer and recent surgery when initially diagnosed with MD. However, imaging examinations, such as ultrasonography or CT examination, should be used to exclude malignancy or other mass compressing the veins [12]. Currently, there is no standard guideline for the treatment of MD. Most authors suggest nonsteroidal antiin ammatory drugs (NSAIDs) should be the primary treatment. Surgery may be consider when symptomatic treatment is invalid, or in cases of relapsed, and thrombectomy or super cial vein resection may be performed [13]. Antibiotic therapy is not required only when there is proof of infection and systemic anticoagulation is not required, but it can be considered in the acute phase [14].
Due to the lack of enough evidence, the potential risk factors remain speculative. MD is often idiopathic.
Symptoms including pain, tenderness and cord-like induration can completely resolve in 4-8 weeks without speci c therapy [2]. A recent study revealed that there was no recurrence and a new cancer after treatment during one-year follow-up.

Conclusion
Conservative treatments, including oral NSAIDs and observation, may be the optimal choice for MD patients. The lesion often spontaneously resolved after several weeks and there is no recurrence and a new cancer during follow-up. Therefore, excessive medical intervention should be avoided.   Ultrasound showing a non-compressible super cial venous thrombosis of right thoracoepigastric vein.

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