Pleurisy (pleuritis) is inflammation of the pleural membranes causing sharp, stabbing chest pain that worsens with inspiration and expiration. It is a clinical diagnosis of exclusion — life-threatening causes of pleuritic chest pain (PE, MI, pneumothorax, aortic dissection) must be ruled out first. [1-2] Viral pleurisy is the most common benign etiology, and treatment centers on NSAIDs for pain control plus management of the underlying cause. [1-2]
1. History
- Pain characterization: Sudden-onset, sharp/stabbing/burning chest pain; worsened by deep breathing, coughing, sneezing, and trunk movement; often well-localized [2]
- Timing: Acute onset; ask about preceding URI symptoms (viral prodrome in 1–2 weeks prior), recent travel, immobilization, surgery [1-2]
- Associated symptoms: Dyspnea, cough (dry or productive), fever, malaise, pleuritic shoulder pain (diaphragmatic irritation via phrenic nerve) [1]
- Important negatives to elicit: Hemoptysis, unilateral leg swelling, syncope, positional component (worse supine → think pericarditis), tearing/ripping quality (aortic dissection), exertional component [2-3]
2. Alarm Features
- Hemodynamic instability (tachycardia, hypotension, hypoxia) → PE, tension pneumothorax, tamponade [3]
- Sudden severe "tearing" pain radiating to back → aortic dissection [3]
- Unilateral absent breath sounds → pneumothorax [3]
- Fever + productive cough + hypoxia → pneumonia with possible empyema [4]
- Hemoptysis, unilateral leg swelling, recent immobilization → PE (found in 5–21% of ED patients with pleuritic chest pain) [2]
- Pain worse supine, relieved leaning forward → pericarditis [5]
- Subcutaneous emphysema → esophageal rupture or pneumomediastinum [3]
3. Medications
- First-line treatment: NSAIDs (ibuprofen 400–800 mg TID or naproxen 500 mg BID) — mainstay of viral/idiopathic pleurisy [1-2]
- Adjunctive analgesia: Acetaminophen if NSAIDs contraindicated; short-course opioids for severe pain refractory to NSAIDs
- Medications that can cause pleurisy/effusions: Nitrofurantoin, dantrolene, methotrexate, dasatinib, amiodarone, procarbazine, clozapine, phenytoin, β-blockers [6]
- Contraindicated: Avoid NSAIDs if renal insufficiency, active GI bleeding, or anticoagulation for PE; aminoglycosides have poor pleural penetration and should be avoided in pleural infections [7-8]
- If infectious etiology: Antibiotics targeted to cause; empiric coverage for parapneumonic effusion includes ceftriaxone + metronidazole or ampicillin-sulbactam [9]
- If autoimmune (SLE/RA): Corticosteroids for moderate-severe cases; mild lupus pleuritis may respond to NSAIDs alone [10]
4. Diet
- No specific dietary triggers for pleurisy
- Hydration: Encourage adequate oral hydration, especially if febrile
- Long-term: If pleurisy secondary to autoimmune disease, anti-inflammatory dietary patterns may be supportive but are not primary therapy
5. Review of Systems
- Pulmonary: Cough, dyspnea, hemoptysis, wheezing
- Cardiovascular: Palpitations, syncope, leg swelling, orthopnea, PND
- GI: Dysphagia, vomiting (esophageal rupture), abdominal pain (pancreatitis, subdiaphragmatic abscess)
- MSK: Joint pain, swelling, morning stiffness (rheumatologic causes) [11-12]
- Dermatologic: Rash (SLE malar rash, dermatomyositis, herpes zoster) [3]
- Constitutional: Fever, weight loss, night sweats (TB, malignancy)
6. Collateral History and Family History
- Collateral: Recent sick contacts, travel history (TB-endemic areas), occupational exposures (asbestos), substance use, IV drug use
- Family history: VTE/hypercoagulable states, autoimmune diseases (SLE, RA, familial Mediterranean fever), malignancy [6]
- Social context: Smoking history (malignancy risk), recent immobilization/long travel (PE risk), hormone use (OCP/HRT)
7. Risk Factors
- Viral infection (most common cause): Coxsackievirus, RSV, influenza, parainfluenza, EBV, CMV, adenovirus [2][13]
- PE risk factors: Immobilization, recent surgery, malignancy, OCP/HRT use, prior VTE, obesity, pregnancy [2]
- Pneumonia: Aspiration risk, COPD, immunosuppression [14]
- Autoimmune: SLE (pleuritis in up to 50%), RA, Sjögren syndrome [10-11]
- Malignancy: Smoking, age >50, asbestos exposure, known cancer [6]
- TB: Endemic area residence, immunosuppression, incarceration, homelessness [14]
8. Differential Diagnosis
Cannot-miss diagnoses
- Pulmonary embolism — most common life-threatening cause (5–21% of ED pleuritic chest pain presentations) [2]
- Pneumothorax — sudden dyspnea, absent breath sounds unilaterally [3]
- Acute coronary syndrome — atypical MI can present with pleuritic pain [2]
- Aortic dissection — tearing pain, pulse differential [3]
- Esophageal rupture — post-emesis, subcutaneous emphysema [3]
Common/important diagnoses
- Pneumonia (parapneumonic pleuritis) [4]
- Pericarditis — positional pain, friction rub, diffuse ST elevation [5][15]
- Viral pleurisy — diagnosis of exclusion after ruling out above [1]
- Autoimmune serositis (SLE, RA) [11-12]
- Malignant pleural disease [6]
- Costochondritis — reproducible tenderness at costochondral junctions [3]
- Musculoskeletal chest wall pain [16]
9. Past Medical History
- Prior episodes of pleurisy or pleuritic chest pain
- History of VTE, hypercoagulable states
- Known autoimmune disease (SLE, RA)
- Malignancy (lung, breast, lymphoma, mesothelioma)
- Recent thoracic surgery or cardiac procedures (Dressler syndrome)
- Chronic liver, kidney, or heart disease (transudative effusions) [6]
- TB exposure or prior treatment
10. Physical Exam
- Vital signs: Tachycardia, tachypnea, hypoxia (concerning for PE, pneumonia, pneumothorax); fever (infection, autoimmune) [3]
- Auscultation: Pleural friction rub — coarse, grating sound heard in both inspiration and expiration, best at lower anterolateral chest wall; distinguishes from pericardial rub (persists with breath-holding) [3]
- Percussion: Dullness suggests effusion; hyperresonance suggests pneumothorax [9]
- Decreased breath sounds over affected area [9]
- Chest wall palpation: Reproducible tenderness at costochondral junctions suggests costochondritis (LR+ for non-ACS) [3]
- Extremities: Unilateral leg swelling (DVT/PE), joint swelling (autoimmune)
- Skin: Malar rash (SLE), dermatomal vesicles (herpes zoster) [3]
11. Lab Studies
- Baseline for all: CBC with differential, CMP, CRP/ESR [1]
- Rule out PE: D-dimer (if low pretest probability by Wells/PERC) [2]
- Rule out ACS: Troponin [2]
- If effusion present and thoracentesis performed: Cell count with differential, pH, glucose, LDH, total protein, Gram stain, culture, cytology [9][14]
- Light's criteria to differentiate exudate vs. transudate [9]
- pH <7.2 → complicated parapneumonic effusion requiring drainage [7]
- If autoimmune suspected: ANA, anti-dsDNA, RF, anti-CCP, complement levels [10][17]
- If TB suspected: Pleural fluid ADA (sensitivity ≥79%, specificity ≥83%), AFB culture, interferon-gamma [14]
- Procalcitonin: May support bacterial infection but not routinely recommended for pleural infection diagnosis [7]
12. Imaging
- First-line: Chest X-ray (PA and lateral) — recommended for all patients with pleuritic chest pain; detects effusions >75 mL (lateral) or >175 mL (frontal), pneumothorax, pneumonia, widened mediastinum [1][18]
- Point-of-care ultrasound (POCUS): Detects effusions as small as 20 mL; superior to CXR for small/occult effusions; identifies septations, guides thoracentesis, reduces procedural complications [6][16][18]
- CT chest: Gold standard for imaging (detects >10 mL fluid); indicated if PE suspected (CTA), malignancy suspected, or CXR inconclusive [18]
- When imaging is unnecessary: Repeat CXR post-thoracentesis not required unless symptomatic, air aspirated, or multiple attempts [9]
- Lung ultrasound showed sensitivity 97% and specificity 96% for detecting radio-occult pleural-pulmonary lesions in patients with pleuritic pain and normal CXR [16]
13. Special Tests
- Wells Score / PERC Rule — validated clinical decision rules for PE risk stratification [2][4]
- HEART Score — for ACS risk stratification if cardiac etiology considered
- Light's Criteria — pleural fluid protein ratio >0.5, LDH ratio >0.6, or pleural LDH >2/3 upper limit of normal serum LDH → exudate [9]
- Thoracentesis — indicated for new-onset unilateral effusions >1 cm on decubitus film or >2 cm on ultrasound/CT, not explained by heart failure/cirrhosis/renal failure [9]
- Pleural biopsy — if TB or malignancy suspected and fluid analysis nondiagnostic [14]
14. ECG
ECG is recommended for all patients with pleuritic chest pain to rule out life-threatening mimics: [1-2]
- Pericarditis: Diffuse concave ST-segment elevation, PR-segment depression (especially leads I, II, aVL, V3–V5); no reciprocal changes; ST/T ratio >0.25 in V6 [5][15]
- Pulmonary embolism: Sinus tachycardia (31%), S1Q3T3 pattern (15%), T-wave inversions V1–V3 (18%), right axis deviation, RBBB (14%) [15][19]
- ACS: ST elevation/depression in coronary distribution with reciprocal changes [15]
- Isolated pleurisy: ECG is typically normal [1]
15. Assessment
- Pleurisy is a clinical syndrome, not a final diagnosis — the underlying etiology must be identified [1]
- Viral pleurisy is the most common benign cause and is a diagnosis of exclusion after ruling out PE, ACS, pneumothorax, pneumonia, and pericarditis [1-2]
- Severity stratification depends on the underlying cause: uncomplicated viral pleurisy is self-limited (1–2 weeks), while PE, empyema, or malignant pleuritis carry significant morbidity/mortality [2]
- Atypical presentations: Elderly patients may present with dyspnea rather than pain; immunocompromised patients may lack fever despite infection [9]
- Complications: Pleural effusion, empyema, fibrothorax, chronic pain, trapped lung [6-7]
16. Treatment Plan
Initial stabilization
- ABCs; supplemental O2 if hypoxic; IV access if hemodynamically unstable
- Treat underlying life-threatening cause immediately (anticoagulation for PE, needle decompression for tension pneumothorax, etc.)
Viral/idiopathic pleurisy
- NSAIDs (ibuprofen 400–800 mg TID or indomethacin 25–50 mg TID) for 1–2 weeks with GI prophylaxis as needed [1-2]
- Encourage incentive spirometry and splinting to prevent atelectasis
Infectious pleurisy
- Antibiotics targeted to cause; empiric coverage for community-acquired parapneumonic effusion: ceftriaxone + metronidazole or ampicillin-sulbactam [8-9]
- Complicated parapneumonic effusion (pH <7.2, glucose <40 mg/dL, positive Gram stain/culture, or pus): chest tube drainage ± intrapleural tPA/DNase [7][9]
Autoimmune pleurisy
Malignant pleurisy
17. Disposition
Admission criteria
- Hemodynamic instability, hypoxia, or respiratory distress
- Confirmed PE (submassive/massive), pneumothorax requiring intervention, empyema
- Large pleural effusion requiring drainage
- Suspected serious underlying etiology (malignancy, aortic dissection)
- Inability to control pain or maintain oral intake
Discharge criteria
- Life-threatening causes excluded (normal CXR, ECG, troponin, low PE probability)
- Hemodynamically stable, adequate oxygenation
- Pain controlled with oral NSAIDs
- Reliable follow-up arranged [1-2]
Observation indications
- Borderline vital signs, pending workup results (D-dimer, serial troponins)
- Small effusion being monitored for progression
Specialist consultation triggers
- Pulmonology: significant or recurrent effusion, need for thoracentesis/chest tube, suspected malignancy [6]
- Cardiology: pericarditis with hemodynamic compromise or myocardial involvement
- Rheumatology: suspected autoimmune serositis [12][20]
- Thoracic surgery: empyema, loculated effusion, fibrothorax [8]
18. Follow Up / Return Precautions
- Follow-up timing: Primary care within 1–2 weeks for uncomplicated viral pleurisy; sooner if symptoms worsen [2]
- Repeat CXR at 6 weeks in patients >50 years, smokers, or those with pneumonia to document radiographic resolution and exclude underlying malignancy [2]
- Return immediately for: Worsening dyspnea, chest pain at rest, hemoptysis, fever >101°F, syncope, unilateral leg swelling, inability to take oral medications
- Expected recovery: Viral pleurisy typically resolves in 1–2 weeks; persistent symptoms beyond 2–4 weeks warrant further workup for autoimmune, malignant, or TB etiologies [1-2]
- Patient counseling: Pleurisy pain may transiently worsen with deep breathing and coughing; splinting the chest with a pillow during coughs can help; avoid smoking; complete full NSAID course
References
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