Pleuritic Chest Pain

Aka: Pleuritic Chest Pain, Pleuritic Pain, Pleurisy

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II. Definitions

  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

III. Pathophysiology

  1. Parietal pleura (not visceral) has Sensory Nerves
    1. Irritated by inflammation or Trauma
  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

IV. Causes: Serious and life-threatening

  1. Pulmonary Embolism (represents 5-20% of Pleurisy in ER)
  2. Pneumothorax or spontaneous Pneumomediastinum
  3. Pneumonia
  4. Pericarditis
  5. Myocarditis
  6. Myocardial Infarction (Pleuritic Pain is atypical)
  7. Aortic Dissection

V. Causes: Infection

  1. Bacteria
    1. Bacterial Pneumonia
    2. Tuberculosis and Tuberculous pleuritis
    3. Rickettsia (Mediterranean Spotted Fever, Rocky Mountain Spotted Fever)
  2. Virus (common)
    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
    2. Paragnomiasis

VI. 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 (esp. malignant Pleural Effusion)
    2. Familial Mediterranean Fever (recurrent episodes)
    3. Sickle Cell Anemia (acute Sickle Cell Crisis)
  4. Inflammatory Conditions
    1. Reactive Eosinophilic pleuritis
    2. Rheumatologic pleuritis (Systemic Lupus, Rheumatoid Arthritis)
    3. Sjogren Syndrome
    4. Ankylosing Spodylitis
  5. Gastrointestinal and Genitourinary Conditions
    1. Inflammatory Bowel Disease
    2. Pancreatitis
    3. Chronic Renal Failure

VII. Symptoms

  1. Sudden and intense, sharp, stabbing or burning 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
      4. Laughing
  4. Radiation
    1. May radiate to neck or Shoulder (via phrenic nerve) when diaphragm is involved
    2. Radiation to arms (especially both arms or right arm) is more suggestive of Acute Coronary Syndrome
    3. Radiation to intrathoracic back (severe intensity) may be seen with Aortic Dissection, Pancreatitis

VIII. Symptoms: Red flags for serious or atypical causes

  1. Sudden, acute onset within minutes (consider life-threatening causes listed above)
  2. Significant Dyspnea (Pulmonary Embolism, Pneumothorax, Pneumonia)
  3. Night Sweats
  4. Significant weight loss
  5. Joint Pain
  6. Syncope
  7. Productive cough

IX. Signs: Red Flags on cardiopulmonary exam

  1. Hypotension
  2. Tachycardia
  3. Tachypnea
  4. Pericardial Friction Rub
  5. Rales, asymmetric or absent lung sounds

X. Labs

  1. Consider D-Dimer
  2. Consider cardiac enzymes

XI. Diagnostic Tests

  1. Chest XRay (obtain in all patients)
    1. Widened mediastinum (Aortic Dissection)
    2. Pneumothorax
    3. Pleural Effusion
    4. Pneumonia
  2. Electrocardiogram
    1. Acute Coronary Syndrome
      1. See Electrocardiogram in Myocardial Infarction
      2. ST Segment changes
      3. New Q Waves or new onset Left Bundle Branch Block
      4. T Wave Inversion
    2. Pulmonary Embolism
      1. See Electrocardiogram in Pulmonary Embolism
      2. Electrocardiogram shows nonspecific changes in 80% of cases
      3. Classic Findings (Right heart strain): S1 Q3 T3 (seen in under 20% of cases)
      4. T Wave Inversion especially in anteroseptal (v1-v4) and possibly inferior (II, III, aVF) leads
    3. Pericarditis
      1. See Electrocardiogram in Pericarditis
      2. Abnormal EKG changes in 90% of Pericarditis cases
      3. PR Segment Depression (without T Wave Inversion)
      4. Diffuse concave upward ST Segment Elevation

XII. Management

  1. NSAIDs for analgesia (preferred over Narcotics)
    1. Indomethacin 50-100 mg orally three times daily with food or milk
    2. Corticosteroids (Prednisone) may be considered in patients unable to take NSAIDS
  2. Identify cause
    1. Evaluate first for serious causes
    2. Consider Medication Causes of Pleural Disease

XIII. References

  1. Kass (2007) Am Fam Physician 75:1357-64 [PubMed]
  2. Reamy (2017) Am Fam Physician 96(5): 306-12 [PubMed]

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