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Pleurisy SARA M. KASS, CDR, MC, USN, PAMELA M. WILLIAMS, MAJ, USAF, MC, and BRIAN V. REAMY, COL, USAF, MC, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Pleuritic is a common presenting symptom and has many causes, which range from life-threatening to benign, self-limited conditions. is the most common potentially life-threatening cause, found in 5 to 20 percent of patients who present to the emergency department with pleuritic pain. Other clinically significant conditions that may cause pleuritic pain include , , , and pneumo- . Patients should be evaluated appropriately for these conditions before an alternative diagnosis is made. History, physical examination, and chest radiography are recommended for all patients with pleuritic chest pain. is helpful, especially if there is clinical suspicion of myocardial infarction, pulmonary embolism, or pericarditis. When these other significant causes of pleuritic pain have been excluded, the diagnosis of pleurisy can be made. There are numerous causes of pleurisy, with viral pleurisy among the most common. Other etiologies may be evaluated through additional diagnostic testing in selected patients. Treatment of pleurisy typically consists of pain management with nonsteroidal anti-inflamma- tory drugs, as well as specific treatments targeted at the underlying cause. (Am Fam Physician 2007;75:1357-64. Copyright © 2007 American Academy of Family Physicians.)

leurisy is of the pari- nerve supplies innervations to the central part etal pleura that typically results in of each hemidiaphragm; when these fibers are characteristic pleuritic pain and has activated, the sensation of pain is referred to a variety of possible causes. The the ipsilateral or shoulder. P term “pleurisy” is often used to refer to a symptom and a condition. It is more precise to use the term “pleurisy” for the condi- It is important that physicians first consider tion and “pleuritic pain” to describe the potentially life-threatening disorders such as symptom. Pleuritic pain is a key feature of pulmonary embolism, myocardial infarction, pleurisy; therefore, this article reviews the and when a patient presents physiology and classic characteristics of pleu- with pleuritic chest pain.1-5 One study of a ritic pain, focusing on the presentation and consecutive series of patients presenting to the diagnosis of the patient and the management emergency department with pleuritic chest of various causes of pleurisy. pain found that 5 percent had a pulmonary embolism6; in another study, the proportion Pathophysiology was 21 percent.7 Pericarditis and pneumonia The visceral pleura does not contain any noci- are two other significant causes of pleuritic ceptors or pain receptors. The parietal pleura chest pain that should be considered before is innervated by somatic nerves that sense pleurisy is diagnosed.8,9 The differential diag- pain when the parietal pleura is inflamed. nosis of pleurisy when these causes have been Inflammation that occurs at the periphery ruled out is presented in Table 1.2,10-18 of the parenchyma can extend into the Viral infection is one of the most common pleural space and involve the parietal pleura, causes of pleurisy. Viruses that have been thereby activating the somatic pain receptors linked as causative agents include , and resulting in pleuritic pain. Parietal pleu- parainfluenza, coxsackieviruses, respiratory rae of the outer rib cage and lateral aspect of syncytial virus, mumps, cytomegalovirus, each hemidiaphragm are innervated by inter- adenovirus, and Epstein-Barr virus.10-12 costal nerves. Pain is localized to the cutane- Additionally, pleurisy may be the first mani- ous distribution of those nerves. The phrenic festation of some less-common disorders.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence Clinical recommendation rating References

A thorough history and physical examination should be performed C 3, 9, 19, 22, 29 to diagnose or exclude life-threatening causes of pleuritic pain before making a diagnosis of pleurisy. Pulmonary embolism is the most common life-threatening cause of C 19 pleuritic chest pain and should be considered in all patients with this symptom. Evaluation should be performed using validated clinical decision rules, d-dimer testing, and imaging studies as needed. Patients with pleuritic pain should have chest radiography to C 9 evaluate for underlying pneumonia. Nonsteroidal anti-inflammatory drugs should be used to control B 30, 31 pleuritic pain.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1289 or http://www.aafp.org/afpsort.xml.

Presentation Table 1. Differential Diagnosis of Pleurisy* Patients with pleuritic pain present in differ- ent ways depending on the underlying cause. Category Etiology Pleuritic pain typically is localized to the area Cardiac Post–cardiac injury syndrome, post–myocardial infarction that is inflamed or along predictable referred syndrome (Dressler’s syndrome), postpericardiotomy pain pathways. Patients’ descriptions of the syndrome (postcommissurotomy syndrome) pain are consistent in most cases of pleurisy. Exposure , some † The classic feature is that forceful Gastrointestinal Inflammatory bowel disease, spontaneous bacterial movement, such as taking a deep breath, pleuritis talking, coughing, or sneezing, exacerbates Genetic Familial Mediterranean the pain. Hematologic/ Malignancy, sickle cell disease Patients often relate that the pain is sharp oncologic and is made worse with movement. Typi- Infectious Viral (e.g., adenovirus, coxsackieviruses, cally, they will assume a posture that limits cytomegalovirus, Epstein-Barr virus, influenza, mumps, parainfluenza, respiratory syncytial virus) motion of the affected area. Pain with res- Bacterial (e.g., Mediterranean spotted fever, piration may cause patients to complain of parapneumonic or tuberculous pleuritis) or dyspnea. Parasitic (e.g., amebiasis, paragonimiasis) Inflammatory Reactive eosinophilic pleuritis Evaluation Renal Chronic renal failure, renal capsular hematoma A recommended approach for the evaluation Rheumatologic pleuritis, rheumatoid pleuritis, Sjögren’s syndrome of patients presenting with pleuritic chest pain is given in Figure 1.3-5,8,9,19-22 Evaluation *—Assumes pulmonary embolism, myocardial infarction, pneumothorax, pericardi- of patients in whom pulmonary embolism tis, and pneumonia have been ruled out as the cause of pleuritic chest pain. is suspected should include an assessment †—Drugs known to cause include amiodarone (Cordarone), bleomycin (Blenoxane), bromocriptine (Parlodel), cyclophosphamide (Cytoxan), methotrex- of the probability of pulmonary embolism ate, methysergide (Sansert; not available in the United States), minoxidil (Loniten), using a validated clinical decision rule, such mitomycin (Mutamycin), oxyprenolol (Apsolox; not available in the United States), 19 d practolol (Eraldin; not available in the United States), procarbazine (Matulane), and as the Wells rule, and a -dimer test. Com- sclerotherapeutic agents. Drugs that may cause lupus pleuritis include hydralazine puted tomography or ventilation- (Apresoline), procainamide (Pronestyl), and quinidine. scanning may be required in patients who Information from references 2 and 10 through 18. are at moderate or high risk or who have an abnormal d-dimer test result.20

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Outpatient Diagnosis of Pleuritic Pain Patient presents with pleuritic pain

History and physical examination

Chest radiography

Normal Abnormal

Clinical suspicion for MI, pulmonary embolism, or pericarditis? Infiltrate Pleural Cardiomegaly Abrupt hilar separation cutoff, oligemia, or pulmonary infarct No Yes Pneumonia Consider pericarditis, ECG Pneumothorax perform ECG Consider pulmonary embolism*

Normal Abnormal

Persistent clinical suspicion of MI?

ST-segment elevation, Sinus , Diffuse concave new Q wave, new RV overload upward ST-segments, No Yes conduction defect PR-segment depression

Persistent clinical suspicion Obtain enzymes of pulmonary embolism? Consider MI, obtain cardiac pulmonary Pericarditis enzymes embolism*

No Yes

Persistent clinical Consider pulmonary suspicion of pericarditis? embolism*

No Yes

Clinical suspicion of less common Observe, consider NSAIDs cause for pleurisy (see Table 4)?

No Yes

Viral pleurisy Proceed with further diagnostic evaluation (as in Table 4)

note: This algorithm combines and simplifies diagnostic recommendations from multiple sources to provide an overview and does not represent a validated clinical decision rule.

*—Apply Wells decision rule to assess pretest probability, order d-dimer and interpret in light of pretest probability, then order further testing as recommended by that diagnostic algorithm.19,20

Figure 1. Algorithm for the outpatient diagnosis of pleuritic pain. (MI = myocardial infarction; ECG = electrocardiography; RV = right ventricular; NSAIDs = nonsteroidal anti-inflammatory drugs.)

Information from references 3 through 5, 8, 9, and 19 through 22.

May 1, 2007 ◆ Volume 75, Number 9 www.aafp.org/afp American Family Physician 1359 Pleurisy Table 2. Etiologies of Pleuritic Pain by Symptom Onset

Onset Etiologies A careful, focused history is the first step in Acute Myocardial infarction (i.e., minutes Pulmonary embolism identifying the underlying etiology of pleu- to hours) ritic pain. A key question is the time course Spontaneous pneumothorax of the onset of symptoms (Table 22). Trauma Although pleuritic pain decreases the like- Subacute Infection (i.e., hours Inflammatory process lihood that a patient with chest pain is to days) experiencing myocardial , it does Chronic Malignancy 3 not eliminate the possibility. If other his- (i.e., days tory findings suggest this diagnosis, further to weeks) evaluation with electrocardiography (ECG) Recurrent Familial Mediterranean fever and cardiac enzymes, as well as close obser- vation, is indicated. Pain that worsens while Information from reference 2. the patient is supine and lessens while the patient is upright should prompt consider- ation of pericarditis.8,21 Dyspnea associated pains, may indicate one of the less-com- with the pain should raise clinical suspicion mon causes of pleurisy. It is important to for pulmonary embolism, pneumonia, and investigate the patient’s underlying medi- pneumothorax.5,9,23 cal conditions, list, and recent Features that are associated with life- travel history, and to take a history of similar threatening causes of pleuritic pain are listed symptoms in family members. A selected in Table 3.3-5,8,9,21,22 Other symptoms, such as differential diagnosis with associated clini- malaise, , night sweats, and joint cal results is listed in Table 4.13-18,24-27

Table 3. Findings Associated with Life-Threatening Causes of Pleuritic Pain

Diagnosis History Physical examination Chest radiography Electrocardiography

Myocardial Substernal pain that Diaphoresis, hypotension, Usually normal ST-T elevations (especially

infarction radiates, dyspnea, third heart sound (S3) if new), new Q wave, shortness of breath new conduction defect Pleuritic pain decreases likelihood ratio Pericarditis Positional pain: increases Pericardial friction rub Increased heart size Diffuse concave upward while supine and with pericardial ST-segments, PR- decreases when upright effusion greater segment depression than 250 mL Abnormality noted in more than 90 percent of cases Pneumonia Anorexia, , dyspnea, , , Infiltrate Typically not indicated fatigue, myalgia Pneumothorax Sudden pain and dyspnea Tachycardia, hyperresonance, Thin pleural line Typically not indicated decreased breath sounds, May be normal in Sinus tachycardia decreased wall movement small pneumothorax Pulmonary Prior embolism or clot Tachycardia, Abrupt hilar Sinus tachycardia, right embolism Cancer, immobilization, cutoff, oligemia, ventricular overload estrogen use, or recent or pulmonary (T-wave inversion in right surgery consolidations precordial leads, S1Q3/ Dyspnea, syncope compatible with S1Q3T3, transient right infarction bundle branch block,

pseudoinfarction, S1S2S3)

Information from references 3 through 5, 8, 9, 21, and 22.

1360 American Family Physician www.aafp.org/afp Volume 75, Number 9 ◆ May 1, 2007 Pleurisy Table 4. Findings Associated with Selected Causes of Pleurisy

Diagnosis History Physical examination Selected diagnostic test results

Connective Prior diagnosis of systemic lupus Decreased breath sounds Chest radiography: small to moderate tissue erythematosus, rheumatoid unilateral or bilateral effusion disorders arthritis, or other connective PFA: exudative effusion (rheumatoid tissue disorder should raise arthritis characterized by low glucose suspicion, but pleuritic level [< 40 mg per dL (2.2 mmol per chest pain may be initial L)], elevated lactic dehydrogenase level presentation [> 700 U per L], and low pH [< 7.2]) Fever; arthritis or arthralgias Abnormal disease-specific serologic markers

Drug-induced Use of drug known to cause Possible decreased breath Chest radiography: may be normal pleuritis drug-induced pleural disease sounds, or demonstrate infiltrate, pleural or drug-induced lupus effusion, or pleural thickening pleuritis* PFA: exudative effusion

Familial Recurrent episodes of fever (one Normal between episodes Increased acute phase reactants (ESR, Mediterranean to four days) associated with During episodes: temperature CRP, WBC, fibrinogen) fever abdominal, chest, or joint pain of 100 to 104° F (38 to Positive mutation analysis for MEFV gene or erysipelas-like skin disease 40° C) and signs of serositis Mediterranean descent (e.g., peritoneal irritation, Family history of familial pleural and/or pericardial Mediterranean fever friction rub) Other possible findings: joint swelling, unilateral erythema over extensor surface of leg, ankle, or foot

Post–cardiac Recent myocardial infarction, Pleural and/or pericardial Chest radiography: may reveal pleural injury cardiac procedure, or chest friction rub; decreased effusion syndrome† trauma breath sounds PFA: exudative effusion Fever, dyspnea, Elevated ESR, leukocytosis pleuropericardial pain Electrocardiographic abnormalities similar to pericarditis (see Table 3)

Tuberculous Exposure to environment with Unilaterally decreased breath Chest radiography: small to moderate pleuritis high risk of Mycobacterium sounds unilateral , often tuberculosis without associated infiltrate Cough, low-grade fever, weight PFA: exudative effusion with elevated loss, fatigue adenosine deaminase levels (> 40 to Human immunodeficiency virus 60 U per L [670 to 1,000 nkat per L]) infection Caseous granulomas on pleural Culture positive for M. tuberculosis on induced , pleural fluid culture, or pleural biopsy Negative PPD result does not exclude diagnosis

Viral pleurisy Recent respiratory illness or Rapid, shallow respirations; Chest radiography: normal undifferentiated febrile illness pleural friction rub

PFA = pleural fluid analysis; ESR = erythrocyte sedimentation rate; CRP = C-reactive protein; WBC = white blood cell count; PPD = purified protein derivative. *—Drugs known to cause pleural disease include amiodarone (Cordarone), bleomycin (Blenoxane), bromocriptine (Parlodel), cyclophosphamide (Cytoxan), , methysergide (Sansert; not available in the United States), minoxidil (Loniten), mitomycin (Mutamycin), oxyprenolol (Apsolox; not available in the United States), practolol (Eraldin; not available in the United States), procarbazine (Matulane), and sclerotherapeutic agents. Drugs that may cause lupus pleuritis include hydralazine (Apresoline), procainamide (Pronestyl), and quinidine. †—Post–cardiac injury syndrome includes post–myocardial infarction syndrome (Dressler’s syndrome) and postpericardiotomy syndrome (postcom- missurotomy syndrome). Information from references 13 through 18 and 24 through 27.

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physical examination movement that occur with pneumothorax.8 The normally smooth surfaces of the pari- Physical examination findings associated etal and visceral pleurae become rough with with life-threatening conditions that cause inflammation. As these surfaces rub against pleuritic pain are listed in Table 3.3-5,8,9,21,22 one another, a rough scratching sound, or Further physical examination is directed by friction rub, may be heard with inspiration the etiology suggested by the clinical history. and expiration. This friction rub is a clas- It is important to remember that patients sic feature of pleurisy. It may also occur in with any of these serious conditions who about 4 percent of patients with pneumonia present with pleuritic pain may have a nor- and 4 percent of patients with pulmonary mal physical examination, and a high index embolism.28 Additional physical findings on of suspicion and further diagnostic testing the pulmonary examination may include are often indicated. decreased breath sounds, rales, and egoph- ony, especially in patients with underlying diagnostic tests pneumonia.9 Because pleuritic chest pain may be a present- Other physical examination findings that ing complaint for pneumonia, pulmonary raise clinical suspicion for certain conditions embolism, or pneumothorax,1,9 all patients include the pericardial rub of pericarditis5 presenting with this symptom should have and the hyperresonance and decreased wall chest radiography. Additionally, pleurisy often is associated with a pleural effusion, which can be identified on a chest radio- Table 5. Initial Evaluation of Pleural Fluid graph. Pleural fluid can be examined for further etiologic clues (Table 529). Quality Test indicated Interpretation ECG evaluation is recommended if there is Appearance clinical suspicion of myocardial infarction, 3,21,28 Bloody Hematocrit < 1 percent: nonsignificant pulmonary embolism, or pericarditis. 1 to 20 percent: cancer, Typical ECG findings associated with these pulmonary embolus, or trauma conditions are listed in Table 3.3-5,8,9,21,22 > 50 percent peripheral When the etiology of pleurisy is other than hematocrit: viral, further diagnostic testing may be indi- Cloudy or turbid Centrifugation Turbid supernatant: cated in selected patients (Table 413-18,24-27). Odor Putrid Stain and Possible anaerobic infection Treatment culture Management of pleurisy has two primary Distinguishing transudate from exudate goals: (1) control the pleuritic chest pain, and Light’s criteria Fluid is exudate if it meets one or more of the (2) treat the underlying condition. To achieve following criteria: pain control, nonsteroidal anti-inflammatory Ratio of pleural fluid protein level to serum protein drugs (NSAIDs) commonly are prescribed as level > 0.5 the initial therapy. Narcotic analgesics may Ratio of pleural fluid LDH level to serum LDH be required to relieve severe pleuritic chest level > 0.6 pain; however, NSAIDs do not suppress Pleural fluid LDH level > two thirds the upper limit respiratory efforts or cough reflex and are the of normal for serum LDH level preferred first-line agent. Confirmation of Fluid is exudate if: Although a class effect is presumed, Light’s criteria Serum albumin level – pleural fluid albumin level assessment* ≤ 1.2 g per dL (12 g per L) human studies on the use of NSAIDs to treat pleuritic chest pain have been limited LDH = lactate dehydrogenase. to indomethacin (Indocin). Indomethacin, *—To use when patient’s clinical appearance suggests transudative effusion. in dosages of 50 to 100 mg orally up to three Adapted with permission from Light RW. Pleural effusion. N Engl J Med 2002; times per day with food, has been found to 346:1974. be effective in relieving pleural pain, with associated improvement in mechanical lung

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function.30,31 Supportive care with adequate pain control is the goal in the treatment of The Authors viral pleurisy. SARA M. KASS, CDR, MC, USN, is an assistant professor To achieve the second management goal, in the Department of Family Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md. therapies are selected based on the under- Dr. Kass graduated from the George Washington University lying condition. If a patient has suspected School of Medicine and Health Sciences in Washington, drug-induced pleuritis or drug-induced D.C. She completed a residency in family medicine at Puget lupus pleuritis, the causal agent should be Sound Family Medicine Residency, Bremerton, Wash. discontinued.16,17 Smoking cessation should PAMELA M. WILLIAMS, MAJ, USAF, MC, is an assistant be advised for patients with pleurisy caused professor in the Department of Family Medicine at the 32 Uniformed Services University of the Health Sciences. Dr. by asbestosis. Antimicrobial and antipara- Williams graduated from the University of Pennsylvania sitic agents are selected empirically based on School of Medicine in Philadelphia. She completed a the suspected underlying organism. Decor- residency in family practice at David Grant USAF Medical tication is considered in cases of pleuritis Center, Travis Air Force Base, Calif., and a fellowship in faculty development with the University of California, San associated with refractory pleural effusions Francisco, School of Medicine. resulting from malignancy, chronic renal 2 BRIAN V. REAMY, COL, USAF, MC, is chair of the failure, or rheumatoid pleurisy. Colchicine Department of Family Medicine at the Uniformed Services (1.2 to 2.0 mg orally once per day, or twice University of the Health Sciences. Dr. Reamy graduated per day in a divided dose) is the mainstay from Georgetown University Medical Center School of of treatment for familial Mediterranean Medicine in Washington, D.C. He completed a residency 18 in family practice at David Grant USAF Medical Center and fever. a fellowship in faculty development at the University of NSAIDs are first-line therapy for patients California, San Francisco, School of Medicine. with post–cardiac injury syndrome; cor- Address correspondence to Sara M. Kass, CDR, MC, USN, ticosteroids are reserved for those who are Uniformed Services University of the Health Sciences, intolerant of or experience no response to 4301 Jones Bridge Rd., Bethesda, MD 20814 (e-mail: NSAIDs.14 Although oral [email protected]). Reprints are not available from the authors. are recommended for patients with lupus pleuritis, they have not been demonstrated Author disclosure: Nothing to disclose. to influence the course of rheumatoid pleuritis.2,15 REFERENCES The role of systemic corticosteroids in 1. Staton GW Jr, Ingram RH Jr. IX. Disorders of the pleura, the treatment of tuberculous pleuritis is hila, and . In: Holtzman MJ. ACP Medicine: 14. Respiratory medicine. Danbury, Conn.: WebMD, controversial. Tuberculous pleuritis is asso- 2005. Accessed December 19, 2006, at: http://www. ciated with inflammation and fibrosis, and acpmedicine.com/abstracts/sam/med1409.htm. a small number of randomized and quasi- 2. Nadel JA, Murray JF, Mason RJ. Textbook of Respira- randomized studies with patients who did tory Medicine. 4th ed. Philadelphia, Pa.: Saunders, 2005:254, 497-8, 856, 1946, 1993, 2235. not have human immunodeficiency virus 3. Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. The have assessed the impact of steroids on this rational clinical examination. Is this patient having a process.33 No difference was detected in the myocardial infarction? JAMA 1998;280:1256-63. primary outcome of an alteration in residual 4. Poulsen SH, Noer I, Moller JE, Knudsen TE, Frandsen JL. Clinical outcome of patients with suspected pulmo- lung function. Although these studies did nary embolism. A follow-up study of 588 consecutive show a trend toward benefit (reduction in patients. J Intern Med 2001;250:137-43. the number of patients with pleural effu- 5. Sahn SA, Heffner JE. Spontaneous pneumothorax. sions, thickening, or adhesions), there is N Engl J Med 2000;342:868-74. insufficient evidence to determine whether 6. Hogg K, Dawson D, Mackway-Jones K. The emergency department utility of Simplify d-dimer to exclude pul- 33 steroids are an effective treatment. monary embolism in patients with pleuritic chest pain. Ann Emerg Med 2005;46:305-10. The opinions and assertions contained herein are the 7. Hull RD, Raskob GE, Carter CJ, Coates G, Gill GJ, Sackett private views of the authors and are not to be construed DL, et al. Pulmonary embolism in outpatients with pleu- as official or as reflecting the views of the Uniformed ritic chest pain. Arch Intern Med 1988;148:838-44. Services University, the U.S. Navy, the U.S. Air Force, or 8. Goyle KK, Walling AD. Diagnosing pericarditis. Am Fam the Department of Defense. Physician 2002;66:1695-702.

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