Can hydroxyzine (an antihistamine) cause pleuritic chest pain?

Hydroxyzine and Pleuritic Chest Pain

Hydroxyzine does not typically cause pleuritic chest pain, and there is no evidence in the medical literature supporting a direct association between hydroxyzine use and pleuritic chest pain.

Understanding Pleuritic Chest Pain

Pleuritic chest pain is characterized by sharp, stabbing, or burning pain that worsens with breathing, coughing, or chest movement. This type of pain originates from inflammation of the pleura (the thin membrane surrounding the lungs) 1.

Common Causes of Pleuritic Chest Pain

The most common serious causes of pleuritic chest pain include:

1. Pulmonary embolism - Most common potentially life-threatening cause (5-21% of emergency department presentations with pleuritic pain) 2
2. Pneumonia - Often accompanied by fever and respiratory symptoms 3
3. Pneumothorax - Characterized by sudden onset of pain and dyspnea 3
4. Pericarditis - Associated with diffuse ST elevation and PR depression on ECG 4
5. Viral infections - Common causative agents include coxsackieviruses, respiratory syncytial virus, influenza, and others 2

Hydroxyzine and Adverse Effects

Hydroxyzine is an antihistamine commonly used for anxiety and pruritus. Its known side effect profile does not typically include pleuritic chest pain. The most common cardiovascular side effects associated with hydroxyzine include:

• Tachycardia - In rare cases, as documented in a case report of a nine-year-old girl who developed supraventricular tachycardia while taking hydroxyzine 5
• Chest tightness - Which may be associated with anxiety or palpitations rather than true pleuritic pain 5

Clinical Evaluation of Pleuritic Chest Pain

When a patient presents with pleuritic chest pain while taking hydroxyzine, clinicians should:

1. Perform a focused cardiovascular examination to rule out serious causes 3
2. Obtain a 12-lead ECG within 10 minutes of presentation 4
3. Order a chest radiograph to assess for pneumonia, pneumothorax, or pleural effusion 4
4. Consider CT angiography if pulmonary embolism is suspected 4

Differential Diagnosis

In a patient taking hydroxyzine who develops pleuritic chest pain, consider:

• Primary causes of pleuritic pain (pulmonary embolism, pneumonia, etc.) unrelated to hydroxyzine
• Anxiety-related chest pain that may be the reason hydroxyzine was prescribed initially
• Rare cardiac effects of hydroxyzine (though these typically present as palpitations or tachycardia rather than pleuritic pain) 5

Management Approach

1. Discontinue hydroxyzine if there is temporal association between starting the medication and onset of symptoms
2. Investigate for common causes of pleuritic chest pain using appropriate diagnostic tests
3. Provide appropriate analgesia with NSAIDs for pain management if no contraindications exist 2
4. Treat the underlying cause once identified

Conclusion

While hydroxyzine has been associated with rare cardiac side effects such as tachycardia, there is no established causal relationship between hydroxyzine and pleuritic chest pain in the medical literature. When evaluating a patient with pleuritic chest pain who is taking hydroxyzine, clinicians should focus on ruling out the common serious causes of this symptom rather than attributing it to the medication without further investigation.