Pleurisy

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]

• 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]

• 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]

• 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]

• 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

• 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)

• 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)

• 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]

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]

• 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

• 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]

• 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]

• 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]

• 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]

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]

• 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]

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

• [10]

Malignant pleurisy

• [9]

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]

• 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

1. Pleurisy. — Kass SM, Williams PM, Reamy BV. American Family Physician. 2007.

2. Pleuritic Chest Pain: Sorting Through the Differential Diagnosis. — Reamy BV, Williams PM, Odom MR. American Family Physician. 2017.

3. 2021 AHA/­ACC/­ASE/­CHEST/­SAEM/­SCCT/­SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/­American Heart Association Joint Committee on Clinical Practice Guidelines. — Gulati M, Levy PD, Mukherjee D, et al. Journal of the American College of Cardiology. 2021.

4. Acute Chest Pain in Adults: Outpatient Evaluation. — McConaghy JR, Sharma M, Patel H. American Family Physician. 2020.

5. Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review. — Cremer PC, Klein AL, Imazio M. The Journal of the American Medical Association. 2024.

6. Pleural Disease. — Feller-Kopman D, Light R. The New England Journal of Medicine. 2018.

7. ERS/­ESTS Statement on the Management of Pleural Infection in Adults. — Bedawi EO, Ricciardi S, Hassan M, et al. The European Respiratory Journal. 2023.

8. The American Association for Thoracic Surgery Consensus Guidelines for the Management of Empyema. — Shen KR, Bribriesco A, Crabtree T, et al. The Journal of Thoracic and Cardiovascular Surgery. 2017.

9. Pleural Effusion: Diagnostic Approach in Adults. — Shen-Wagner J, Gamble C, MacGilvray P. American Family Physician. 2023.

10. Lung Involvements in Rheumatic Diseases: Update on the Epidemiology, Pathogenesis, Clinical Features, and Treatment. — Ha YJ, Lee YJ, Kang EH. BioMed Research International. 2017.

11. Systemic Lupus Erythematosus and Lung Involvement: A Comprehensive Review. — Shin JI, Lee KH, Park S, et al. Journal of Clinical Medicine. 2022.

12. Thoracic Involvement in Systemic Autoimmune Rheumatic Diseases: Pathogenesis and Management. — De Zorzi E, Spagnolo P, Cocconcelli E, et al. Clinical Reviews in Allergy & Immunology. 2022.

13. Viral Diseases Affecting the Pleura. — Nestor J, Huggins T, Kummerfeldt C, et al. Journal of Clinical Virology : The Official Publication of the Pan American Society for Clinical Virology. 2013.

14. Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). — Miller JM, Binnicker MJ, Campbell S, et al. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America. 2024.

15. Acute Pericarditis: Rapid Evidence Review. — Peterson TA, Turner SP, Dolezal KA. American Family Physician. 2024.

16. A Comparison of Different Diagnostic Tests in the Bedside Evaluation of Pleuritic Pain in the ED. — Volpicelli G, Cardinale L, Berchialla P, et al. The American Journal of Emergency Medicine. 2012.

17. Immune Complexes and Other Laboratory Features of Pleural Effusions: A Comparison of Rheumatoid Arthritis, Systemic Lupus Erythematosus, and Other Diseases. — Halla JT, Schrohenloher RE, Volanakis JE. Annals of Internal Medicine. 1980.

18. ACR Appropriateness Criteria® Workup of Pleural Effusion or Pleural Disease. — Morris MF, Henry TS, Raptis CA, et al. Journal of the American College of Radiology : JACR. 2024.

19. Prevalence of Electrocardiographic Abnormalities in Patients With Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis. — Krintratun S, Srichuachom W, Wongtanasarasin W. Journal of Clinical Medicine. 2025.

20. Pleural Diseases in Connective Tissue Diseases. — Guo H, Iqbal B, Rahman NM. Seminars in Respiratory and Critical Care Medicine. 2024.