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 chest pain is a common presenting symptom and has many causes, which range from life-threatening to benign, self-limited conditions. Pulmonary embolism 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 pericarditis, pneumonia, myocardial infarction, and pneumo- thorax. 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. Electrocardiography 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 inflammation 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 neck or shoulder. P term “pleurisy” is often used to refer to a symptom and a condition. It is more precise Differential Diagnosis 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 pneumothorax 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 lung 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 influenza, 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. Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2007 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Pleurisy 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 Asbestosis, some medications† The classic feature is that forceful breathing Gastrointestinal Inflammatory bowel disease, spontaneous bacterial movement, such as taking a deep breath, pleuritis talking, coughing, or sneezing, exacerbates Genetic Familial Mediterranean fever 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) shortness of breath 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 Lupus 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 pleural disease 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-perfusion (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 1358 American Family Physician www.aafp.org/afp Volume 75, Number 9 ◆ May 1, 2007 Pleurisy 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 tachycardia, 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