Pleuritis

Background

• Pleuritis (pleurisy) is inflammation of the parietal pleura, producing characteristic pleuritic chest pain
• Most often follows a viral illness (viral pleuritis is the most common cause)
• Pleuritis is a diagnosis of exclusion — must rule out life-threatening causes of pleuritic chest pain before attributing symptoms to benign pleurisy
• Key EM concern: pulmonary embolism, pneumonia, pericarditis, and pneumothorax all cause pleuritic chest pain and must be considered

Clinical Features

History

• Sharp, well-localized chest pain
• Worse with respiration, coughing, sneezing, or movement
• May be positional (worse lying flat, better sitting forward — though this is more classic for pericarditis)
• May complain of shortness of breath secondary to splinting from pain
• Recent viral illness (prodromal URI symptoms suggest viral pleuritis)
• Risk factors for PE: immobility, OCP use, recent surgery, malignancy, prior DVT/PE
• Fever (pneumonia, empyema, TB)

Physical Exam

• Pleural friction rub (coarse, grating sound heard during respiration) — pathognomonic but not always present
• Decreased breath sounds (associated effusion)
• Splinting (shallow breaths to minimize pain)
• Point tenderness may be present (but also consider musculoskeletal causes)
• Assess for signs of underlying cause: fever, tachycardia, hypoxia, unilateral leg swelling

Red Flags

• Hypoxia or tachycardia (PE, large effusion, pneumonia)
• Hemodynamic instability (massive PE, tension pneumothorax)
• Unilateral leg swelling (DVT → PE)
• Fever + productive cough (pneumonia, empyema)
• Recent malignancy (malignant effusion)
• Diffuse ST changes on ECG (pericarditis vs. ACS)
• Absent breath sounds (pneumothorax)

Differential Diagnosis

Must Rule Out

• Pulmonary embolism — most important diagnosis to exclude
• Pneumonia / parapneumonic effusion / empyema
• Pericarditis / myocarditis
• Myocardial infarction (atypical presentation)
• Pneumothorax
• Aortic dissection (pleuritic component possible)

Other Causes of Pleuritic Pain

• Pleural effusion (any cause)
• Tuberculosis
• Autoimmune: SLE, rheumatoid arthritis
• Malignancy: mesothelioma, metastatic disease
• Musculoskeletal: costochondritis, rib fracture, muscle strain
• Subdiaphragmatic: hepatic abscess, splenic infarct, pancreatitis
• Drug-induced: hydralazine, procainamide, isoniazid (drug-induced lupus)

Chest pain

Critical

• Acute coronary syndromes (ACS)
  • STEMI
  • Non-STEMI
  • Unstable angina
• Aortic dissection
• Cardiac tamponade
• Coronary artery dissection
• Esophageal perforation (Boerhhaave's syndrome)
• Pulmonary embolism
• Tension pneumothorax

Emergent

• Cholecystitis
• Cocaine-associated chest pain
• Mediastinitis
• Myocardial rupture
• Myocarditis
• Pancreatitis
• Pericarditis
• Pneumothorax

Nonemergent

• Aortic stenosis
• Arthritis
• Asthma exacerbation
• Biliary colic
• Costochondritis
• Esophageal spasm
• Gastroesophageal reflux disease
• Herpes zoster / Postherpetic Neuralgia
• Hypertrophic cardiomyopathy
• Hyperventilation
• Mitral valve prolapse
• Panic attack
• Peptic ulcer disease
• Pleuritis
• Pneumomediastinum
• Pneumonia
• Rib fracture
• Stable angina
• Thoracic outlet syndrome
• Valvular heart disease
• Muscle sprain
• Psychologic / Somatic Chest Pain
• Spinal Root Compression
• Tumor

Evaluation

Initial

• ECG: rule out MI, pericarditis (diffuse ST elevation with PR depression)
• CXR: pneumonia, effusion, pneumothorax, widened mediastinum
• Pulse oximetry

Laboratory

• CBC, BMP
• Troponin if any concern for ACS or myocarditis
• D-dimer if PE is on the differential and patient is low-to-moderate risk (use Wells criteria or PERC rule)
• ESR, CRP if inflammatory/autoimmune process suspected
• Consider BNP if effusion or heart failure suspected

Advanced Imaging

• CT angiography (CTA chest): if PE suspected — low threshold to obtain in patients with risk factors
• CT chest without contrast: if concern for parenchymal disease, effusion characterization
• Bedside POCUS: evaluate for pleural effusion, pneumothorax, pericardial effusion, RV strain (PE)
• Echocardiography: if pericarditis or myocarditis suspected

Diagnosis

• Viral pleuritis is a clinical diagnosis made after excluding dangerous causes
• Young, otherwise healthy patient with recent viral illness and no red flags may need only ECG and CXR

Management

Symptomatic Treatment

• NSAIDs are first-line treatment
  • Indomethacin 25-50mg TID (most studied agent for pleurisy)
  • Ibuprofen 600-800mg TID is a reasonable alternative
  • Ketorolac 15-30mg IV for acute pain relief in ED
• Acetaminophen as adjunct
• Avoid opioids if possible (respiratory depression can worsen splinting)
• Short course of oral corticosteroids may be considered for refractory cases

Treat Underlying Cause

• PE → anticoagulation
• Pneumonia → antibiotics
• Pericarditis → NSAIDs + colchicine
• Empyema → antibiotics + drainage
• Pneumothorax → observation or chest tube

Disposition

Admit

• Identified underlying cause requiring inpatient management (PE, pneumonia, empyema)
• Large pleural effusion
• Hypoxia
• Hemodynamic instability

Discharge

• Viral pleuritis with normal workup, adequate pain control, and ability to breathe comfortably
• Prescribe NSAIDs for 1-2 weeks
• Follow-up with PCP in 1-2 weeks if symptoms not improving
• Return precautions: worsening pain, shortness of breath, fever, coughing blood, leg swelling, lightheadedness

See Also

• Acute chest pain
• Pulmonary embolism
• Pericarditis
• Pleural effusion
• Pneumothorax