II. Definitions
- Pleuritic Chest Pain (Symptom)
- Chest Pain exacerbated by forceful breathing
- Pleurisy
- Inflammation of parietal pleura
- One of many conditions resulting in Pleuritic Pain
III. Pathophysiology
- Parietal pleura (not visceral) has Sensory Nerves
- Irritated by inflammation or Trauma
- Nerve distribution
IV. Causes: Serious and life-threatening
- Pulmonary Embolism (represents 5-20% of Pleurisy in ER)
- Pneumothorax or spontaneous Pneumomediastinum
- Pneumonia
- Pericarditis
- Myocarditis
- Myocardial Infarction (Pleuritic Pain is atypical)
- Aortic Dissection
V. Causes: Infection
-
Bacteria
- Bacterial Pneumonia
- Tuberculosis and Tuberculous pleuritis
- Rickettsia (Mediterranean Spotted Fever, Rocky Mountain Spotted Fever)
-
Virus (common)
- Adenovirus
- Coxsachievirus
- Cytomegalovirus (CMV)
- Epstein-Barr Virus (EBV)
- Influenza
- Parainfluenza
- Respiratory Syncytial Virus
- Mumps
-
Parasite
- Amebiasis
- Paragnomiasis
VI. Causes: Other
- Musculoskeletal Causes
- Cardiopulmonary Causes
- Post-Myocardial Infarction, Cardiac injury, surgery
- Asbestosis
- Hematologic and oncologic conditions
- Malignancy (esp. malignant Pleural Effusion)
- Familial Mediterranean Fever (recurrent episodes)
- Sickle Cell Anemia (acute Sickle Cell Crisis)
- Inflammatory Conditions
- Reactive Eosinophilic pleuritis
- Rheumatologic pleuritis (Systemic Lupus, Rheumatoid Arthritis)
- Sjogren Syndrome
- Ankylosing Spodylitis
- Gastrointestinal and Genitourinary Conditions
VII. Symptoms
- Sudden and intense, sharp, stabbing or burning Chest Pain on forceful breathing
- Perceived Dyspnea (due to suppressed respirations)
- Provocative factors
- Movement
- Forceful breathing
- Deep breathing
- Coughing
- Sneezing
- Laughing
- Radiation
- May radiate to neck or Shoulder (via phrenic nerve) when diaphragm is involved
- Radiation to arms (especially both arms or right arm) is more suggestive of Acute Coronary Syndrome
- Radiation to intrathoracic back (severe intensity) may be seen with Aortic Dissection, Pancreatitis
VIII. Symptoms: Red flags for serious or atypical causes
- Sudden, acute onset within minutes (consider life-threatening causes listed above)
- Significant Dyspnea (Pulmonary Embolism, Pneumothorax, Pneumonia)
- Night Sweats
- Significant weight loss
- Joint Pain
- Syncope
- Productive cough
IX. Signs: Red Flags on cardiopulmonary exam
- Hypotension
- Tachycardia
- Tachypnea
- Pericardial Friction Rub
- Rales, asymmetric or absent lung sounds
X. Labs
- Consider D-Dimer
- Consider cardiac enzymes
XI. Diagnostic Tests
-
Chest XRay (obtain in all patients)
- Widened mediastinum (Aortic Dissection)
- Pneumothorax
- Pleural Effusion
- Pneumonia
-
Electrocardiogram
-
Acute Coronary Syndrome
- See Electrocardiogram in Myocardial Infarction
- ST Segment changes
- New Q Waves or new onset Left Bundle Branch Block
- T Wave Inversion
-
Pulmonary Embolism
- See Electrocardiogram in Pulmonary Embolism
- Electrocardiogram shows nonspecific changes in 80% of cases
- Classic Findings (Right heart strain): S1 Q3 T3 (seen in under 20% of cases)
- T Wave Inversion especially in anteroseptal (v1-v4) and possibly inferior (II, III, aVF) leads
-
Pericarditis
- See Electrocardiogram in Pericarditis
- Abnormal EKG changes in 90% of Pericarditis cases
- PR Segment Depression (without T Wave Inversion)
- Diffuse concave upward ST Segment Elevation
-
Acute Coronary Syndrome
XII. Management
-
NSAIDs for analgesia (preferred over Narcotics)
- Indomethacin 50-100 mg orally three times daily with food or milk
- Corticosteroids (Prednisone) may be considered in patients unable to take NSAIDS
- Identify cause
- Evaluate first for serious causes
- Consider Medication Causes of Pleural Disease