What is the etiology of pleuritic chest pain?

Etiology of Pleuritic Chest Pain

Pulmonary embolism is the most common serious cause of pleuritic chest pain, occurring in 5-21% of patients presenting with this symptom to emergency departments. 1

Definition and Characteristics

Pleuritic chest pain is characterized by sharp, stabbing, or burning pain in the chest that worsens during inspiration and expiration. This pain results from inflammation of the pleura, which can be caused by various conditions affecting the lungs or pleural space.

Major Causes of Pleuritic Chest Pain

Pulmonary Causes

1. Pulmonary Embolism (PE)

   • Most common serious cause 1
   • Present in 80% of PE patients with dyspnea and 52% with chest pain 2, 3
   • Pain is typically sudden in onset and may be accompanied by dyspnea, tachypnea, hemoptysis, or syncope 3
   • Often disproportionate to radiographic findings 4

2. Pneumonia

   • Common infectious cause 5
   • Typically accompanied by fever, productive cough, and systemic symptoms 6
   • May coexist with or mask PE 6

3. Pneumothorax

   • Characterized by acute chest pain and dyspnea 5
   • Primary spontaneous pneumothorax presents with sudden-onset pain

4. Pleural Effusion

   • May be a consequence of PE (fourth leading cause of pleural effusion) 4
   • Approximately 75% of patients with PE and pleural effusion experience pleuritic chest pain 4

5. Viral Pleuritis

   • Common benign cause 1
   • Associated viruses include coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus 1

6. Asbestos-Related Pleural Disease

   • Can cause acute pleural effusion with fever and severe pleuritic pain 2
   • May persist for months, present bilaterally, or recur 2
   • Chronic pleuritic pain is rare in asbestos-related pleural disease 2

Cardiovascular Causes

1. Myocardial Infarction

   • Must be ruled out in all patients with chest pain 1
   • May present with pleuritic features, especially with right ventricular involvement

2. Pericarditis

   • Sharp, positional pain that may worsen when lying down 1
   • Often preceded by viral illness

3. Aortic Dissection

   • Severe, tearing pain that may have pleuritic components 1
   • Medical emergency requiring immediate intervention

Diagnostic Approach

When evaluating pleuritic chest pain, a systematic approach is essential:

1. Risk Stratification

   • Apply validated clinical decision rules for PE (Wells score or revised Geneva score) 3
   • Consider age, comorbidities, and risk factors for various etiologies

2. Initial Testing

   • Chest radiography to evaluate for pneumonia, pneumothorax, or pleural effusion 1
   • ECG to rule out myocardial infarction or pericarditis 2
   • D-dimer testing when PE is suspected (high negative predictive value) 3, 7

3. Advanced Imaging

   • CT pulmonary angiography for suspected PE (first-line imaging) 3
   • Ventilation-perfusion scan when CTPA is contraindicated 3
   • Echocardiography for risk stratification in PE or evaluation of pericarditis 3

Clinical Pearls and Pitfalls

• PE is the most common cause of pleuritic chest pain and pleural effusion in patients under 40 years 4
• Dyspnea in PE is often disproportionate to the size of any pleural effusion 4
• PE may coexist with pneumonia, and worsening symptoms during treatment of pneumonia should raise suspicion for PE 6
• In patients with persistent symptoms, smokers, and those older than 50 years with pneumonia, follow-up chest radiography is recommended 6 weeks after initial treatment 1
• Chronic severe pleuritic pain is rare in asbestos-related pleural disease but may occur following pleural effusions 2

Treatment Considerations

Treatment should target the underlying cause:

• Anticoagulation for PE 3, 7
• Antibiotics for bacterial pneumonia 6
• NSAIDs for viral or nonspecific pleuritic chest pain 1
• Drainage for significant pneumothorax or symptomatic pleural effusion
• Specific therapy for other identified causes

By systematically evaluating patients with pleuritic chest pain and maintaining a high index of suspicion for serious causes like pulmonary embolism, clinicians can ensure appropriate diagnosis and management of this common but potentially serious symptom.