From the Guidelines
Pleuritic chest pain is primarily caused by inflammation of the pleura, and the most critical cause to identify and treat promptly is pulmonary embolism, as it is a life-threatening condition. The causes of pleuritic chest pain can be varied, including respiratory infections such as pneumonia, viral pleurisy, and bronchitis 1. Other significant causes include pneumothorax (collapsed lung), pericarditis (inflammation of the heart sac), autoimmune conditions like lupus or rheumatoid arthritis, and chest trauma. Certain cancers, particularly lung cancer and mesothelioma, can invade the pleura and cause pain 1. Gastrointestinal conditions like pancreatitis and cholecystitis may refer pain to the chest.
The pain typically worsens with breathing, coughing, or chest movement because these actions increase friction between the inflamed pleural layers. According to the most recent guidelines, the initial evaluation of chest pain should focus on life-threatening causes such as acute coronary syndrome (ACS), pulmonary embolism (PE), aortic dissection, and esophageal rupture to facilitate rapid implementation of appropriate treatment 1.
Some key points to consider in the evaluation of pleuritic chest pain include:
- The presence of chest tenderness on palpation or pain with inspiration can reduce the probability of ACS 1
- Integrating the examination with other elements of the evaluation is crucial to establishing the correct diagnosis 1
- Pulmonary embolism is a critical cause of pleuritic chest pain that requires immediate medical attention, and its diagnosis should be considered in patients with sudden onset dyspnea, chest pain, or syncope 1
- The diagnosis of acute asbestos-related pleural effusion is by exclusion of other causes of acute pleuritis, and most often is not arrived at until the pleural space is fully explored and biopsied, generally by thoracoscopy 1
Given the potential for life-threatening conditions, anyone experiencing sudden, severe chest pain should seek immediate medical evaluation to rule out conditions like heart attack or pulmonary embolism. Treatment depends on identifying and addressing the underlying cause, often including anti-inflammatory medications for symptom relief.
From the Research
Causes of Pleuritic Chest Pain
Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling 2. The causes of pleuritic chest pain can be diverse, ranging from life-threatening to benign, self-limited conditions 3. Some of the common causes include:
- Pulmonary embolism, found in 5% to 21% of patients who present to an emergency department with pleuritic chest pain 2, 3, 4
- Myocardial infarction
- Pericarditis
- Aortic dissection
- Pneumonia
- Pneumothorax
- Viral pleurisy, with viruses such as Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus being likely pathogens 2
Diagnosis and Evaluation
Diagnosis and evaluation of pleuritic chest pain involve a combination of history, physical examination, electrocardiography, troponin assays, and chest radiography 2, 3, 5. Validated clinical decision rules, such as the Wells' score, can be employed to guide the use of additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography 2, 6.
Treatment and Management
Treatment of pleuritic chest pain is guided by the underlying diagnosis 2, 3. Nonsteroidal anti-inflammatory drugs are appropriate for pain management in those with virally triggered or nonspecific pleuritic chest pain 2, 3. In patients with persistent symptoms, persons who smoke, and those older than 50 years with pneumonia, it is important to document radiographic resolution with repeat chest radiography six weeks after initial treatment 2.