Pleuritic Chest Pain

1. Definition
   1. Pleuritic Chest Pain (Symptom)
      1. Chest Pain exacerbated by forceful breathing
   2. Pleurisy
      1. Inflammation of parietal pleura
      2. One of many conditions resulting in Pleuritic Pain
2. Pathophysiology
   1. Parietal pleura (not visceral) has sensory nerves
   2. Nerve distribution
      1. Intercostal nerves referred to associated dermatomes
         1. Rib Cage
         2. Lateral hemidiaphragm
      2. Phrenic nerve referred to ipsilateral neck, Shoulder
         1. Central hemidiaphragm
3. Causes: Serious and life-threatening
   1. Pulmonary Embolism (represents 5-20% of Pleurisy in ER)
   2. Pneumothorax
   3. Pneumonia
   4. Pericarditis
   5. Myocardial Infarction (Pleuritic Pain is atypical)
   6. Spontaneous Pneumomediastinum
4. Causes: Infection
   1. Bacteria
      1. Bacterial Pneumonia
      2. Tuberculous pleuritis
      3. Mediterranean Spotted Fever, Tuberculosis
   2. Virus
      1. Adenovirus
      2. Coxsachievirus
      3. Cytomegalovirus (CMV)
      4. Epstein-Barr Virus (EBV)
      5. Influenza
      6. Parainfluenza
      7. Respiratory Syncytial Virus
      8. Mumps
   3. Parasite
      1. Amebiasis
5. Causes: Other
   1. Musculoskeletal Causes
      1. Musculoskeletal Chest Pain
      2. Cough fracture
   2. Cardiopulmonary Causes
      1. Post-Myocardial Infarction, Cardiac injury, surgery
      2. Asbestosis
   3. Hematologic and oncologic conditions
      1. Malignancy
      2. Familial Mediterranean Fever (recurrent episodes)
      3. Sickle Cell Anemia
   4. Inflammatory Conditions
      1. Reactive Eosinophilic pleuritis
      2. Rheumatologic pleuritis (Lupus, Rheumatoid Arthritis)
      3. Sjogren's Syndrome
   5. Other Conditions
      1. Inflammatory Bowel Disease
      2. Chronic Renal Failure
6. Symptoms
   1. Sharp Chest Pain on forceful breathing
   2. Perceived Dyspnea (due to suppressed respirations)
   3. Provocative factors
      1. Movement
      2. Forceful breathing
         1. Deep breathing
         2. Coughing
         3. Sneezing
7. Symptoms: Red flags for serious or atypical causes
   1. Night Sweats
   2. Significant weight loss
   3. Joint pain
   4. Syncope
   5. Productive cough
8. Signs: Red Flags on cardiopulmonary exam
   1. Hypotension
   2. Tachycardia
   3. Tachypnea
   4. Pericardial Friction Rub
   5. Rales, asymmetric or absent lung sounds
9. Labs
   1. Consider D-Dimer
   2. Consider cardiac enzymes
10. Diagnostic Tests
    1. Chest XRay (obtain in all patients)
    2. Consider Electrocardiogram
11. Management
    1. NSAIDs for analgesia (preferred over Narcotics)
       1. Indomethacin 50-100 mg PO tid with food or milk
    2. Identify cause
       1. Evaluate first for serious causes
       2. Consider Medication Causes of Pleural Disease
12. References
    1. Kass (2007) Am Fam Physician 75:1357-64