How are pleurisy and costochondritis treated?

Treatment of Pleurisy vs. Costochondritis

Pleurisy Treatment

For pleurisy, treatment should focus on addressing the underlying cause and managing pain with nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy. 1

Diagnostic Differentiation

• Pleurisy: Characterized by sharp chest pain that worsens with breathing, coughing, or chest movement. Pain is typically pleuritic (worsens with inspiration) 2
• Costochondritis: Presents with tenderness of costochondral joints, often reproduced by palpation of the affected area 2

Treatment Algorithm for Pleurisy

1. Pain Management:

   • First-line: NSAIDs for 1-2 weeks 2
   • For severe pain: Consider adding low-dose colchicine 2

2. Treatment Based on Underlying Cause:

   • Infectious pleurisy:

     • Viral: Supportive care with NSAIDs
     • Bacterial: Appropriate antibiotics based on suspected organism
       • Community-acquired: Second-generation cephalosporin (e.g., cefuroxime) or aminopenicillin (e.g., amoxicillin) 2
       • Consider adding beta-lactamase inhibitor or metronidazole if anaerobes suspected 2

   • Pleural effusion management:

     • If significant effusion present: Diagnostic thoracentesis
     • For empyema: Chest tube drainage 2
     • For loculated effusions: Consider intrapleural fibrinolytic drugs (streptokinase 250,000 IU twice daily for 3 days or urokinase 100,000 IU once daily for 3 days) 2

3. Monitoring:

   • Follow-up chest imaging to assess resolution
   • Monitor for complications such as pleural thickening or fibrosis 2

Costochondritis Treatment

Treatment Algorithm for Costochondritis

1. First-line Treatment:

   • NSAIDs for 1-2 weeks 2
   • Local heat application
   • Activity modification to avoid exacerbating movements

2. For Persistent Symptoms:

   • Consider physical therapy with focus on:
     • Soft tissue mobilization
     • Stretching exercises
     • Manual therapy techniques 3
   • Local injection of anesthetic with corticosteroid for refractory cases 4

3. Rule Out Infectious Costochondritis:

   • If purulent drainage, fever, or worsening despite treatment, consider infectious etiology
   • Infectious costochondritis requires antibiotics and possibly surgical debridement 5

Important Clinical Considerations

Red Flags Requiring Immediate Attention

• Severe shortness of breath
• Hypotension or tachycardia
• Fever with purulent sputum
• Signs of tamponade
• Unilateral absence of breath sounds (possible pneumothorax) 2

Diagnostic Approach

• Chest radiography is recommended for all patients with pleuritic chest pain 2
• ECG should be performed to rule out cardiac causes, especially with high clinical suspicion of ACS, PE, or pericarditis 2
• For costochondritis, diagnosis is primarily clinical with tenderness on palpation of costochondral joints 2

Common Pitfalls

1. Failing to rule out serious causes of chest pain before diagnosing costochondritis or pleurisy
2. Treating symptoms without addressing underlying cause in pleurisy
3. Overuse of imaging in typical costochondritis presentations
4. Delayed diagnosis of infectious costochondritis, which requires antibiotics and possibly surgical intervention

Special Populations

• Elderly patients: May have atypical presentations; maintain high suspicion for serious underlying conditions
• Immunocompromised patients: Higher risk of infectious etiologies; lower threshold for diagnostic testing
• Patients with history of connective tissue disorders: Consider autoimmune causes of pleurisy

Remember that both conditions can significantly impact quality of life, and prompt, appropriate treatment is essential to reduce morbidity and improve outcomes.