What is pleuritic chest pain?

What is Pleuritic Chest Pain?

Pleuritic chest pain is sharp or knife-like pain provoked by respiration or cough, resulting from inflammation of the pleural surfaces. 1

Characteristics of Pleuritic Chest Pain

Pleuritic chest pain has several distinctive features:

• Pain quality: Sharp, stabbing, or knife-like pain
• Timing: Pain occurs specifically during breathing movements (inspiration and/or expiration)
• Exacerbating factors: Worsened by deep breathing, coughing, sneezing, or laughing
• Location: Often localized to a specific area of the chest wall
• Duration: May be persistent or intermittent, depending on the underlying cause

This type of pain is distinctly different from the deep, poorly localized chest pain characteristic of myocardial ischemia (angina), which is typically associated with exertion or emotional stress and relieved by rest or nitroglycerin 1.

Pathophysiology

Pleuritic pain occurs when inflamed pleural surfaces rub against each other during respiratory movements. The parietal pleura (outer layer lining the chest wall) is richly innervated with pain fibers, while the visceral pleura (covering the lungs) has minimal innervation. Inflammation causes the normally smooth pleural surfaces to become rough, creating friction during breathing movements 1.

Common Causes

Several conditions can cause pleuritic chest pain:

1. Pulmonary Embolism (PE)

   • Most common potentially life-threatening cause (found in 5-20% of emergency department patients with pleuritic pain)
   • Often presents with dyspnea out of proportion to the size of any pleural effusion
   • About 75% of patients with PE and pleural effusion have pleuritic chest pain 2
   • Most common cause of pleuritic chest pain in patients under 40 years 2

2. Pneumonia

   • Infection causes inflammation of lung tissue and adjacent pleura
   • Often accompanied by fever, cough, and sputum production 3

3. Viral Pleurisy

   • Common cause of pleuritic pain
   • Caused by viruses like coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, and others 3

4. Pneumothorax

   • Characterized by sudden onset of sharp chest pain and dyspnea
   • Pain may be severe and is typically unilateral 4

5. Pericarditis

   • Inflammation of the pericardium often causes pleuritic-type pain
   • Pain may improve when sitting up or leaning forward 1

6. Pleural Effusion

   • Fluid accumulation between pleural layers
   • May be a result of other conditions like PE, infection, or malignancy 1

7. Post-pericardiotomy Syndrome

   • Occurs in 10-40% of patients after cardiac surgery
   • Characterized by fever, chest pain, and pericardial or pleural friction rub 5

8. Asbestos-related Pleural Disease

   • Acute pleuritis may occur with asbestos exposure
   • Can lead to pleural effusion and chronic pleural thickening 1

Differentiating from Cardiac Chest Pain

Pleuritic chest pain is a feature that helps distinguish non-cardiac from cardiac causes of chest pain. Features not characteristic of myocardial ischemia include:

• Pleuritic pain (sharp or knife-like pain provoked by respiration or cough)
• Pain localized by the tip of one finger
• Pain reproduced with movement or palpation of the chest wall
• Brief episodes of pain lasting a few seconds
• Pain that is of maximal intensity at onset 1

Diagnostic Approach

When evaluating pleuritic chest pain:

1. History and physical examination

   • Determine if pain is related to breathing movements
   • Check for fever, cough, or other associated symptoms
   • Listen for pleural friction rub (often transient)

2. Chest radiography

   • Essential for all patients with pleuritic chest pain
   • May show infiltrates, effusions, pneumothorax, or other abnormalities 3

3. Electrocardiography

   • Particularly important if there is suspicion of myocardial infarction, pulmonary embolism, or pericarditis 6

4. Additional testing based on clinical suspicion:

   • D-dimer testing as a screen for pulmonary embolism
   • Spiral CT if pulmonary embolism is suspected
   • Echocardiography if pericarditis is suspected 1

Treatment

Management of pleuritic chest pain depends on the underlying cause:

• Pain management: NSAIDs are appropriate for pain management in viral or nonspecific pleuritic chest pain 3
• Specific treatment: Address the underlying cause (antibiotics for pneumonia, anticoagulation for pulmonary embolism, etc.)
• Follow-up: In patients with persistent symptoms, smokers, and those older than 50 years with pneumonia, repeat chest radiography six weeks after initial treatment is recommended 3

Clinical Pitfalls and Caveats

• Despite typical characteristics increasing the probability of non-cardiac causes, atypical features do not exclude Acute Coronary Syndrome (ACS). In the Multicenter Chest Pain Study, acute ischemia was diagnosed in 22% of patients with sharp or stabbing pain and in 13% of those with pleuritic pain 1.
• Pulmonary embolism should always be considered in unexplained pleuritic chest pain, especially in younger patients.
• In patients with COPD exacerbation and chest pain, always consider possible cardiac comorbidity such as ACS 4.
• The absence of pleuritic features does not rule out serious pulmonary conditions like pulmonary embolism.