What are the most common causes of pleuritic chest pain?

Most Common Causes of Pleuritic Chest Pain

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

Definition and Characteristics

• Pleuritic chest pain is sharp, stabbing, or burning pain that is provoked or worsened by respiration, typically localized and may be described as "knifelike" in quality 2
• The pain occurs due to inflammation or irritation of the pleura, and is most intense during deep breathing, coughing, or other respiratory movements 2

Major Causes of Pleuritic Chest Pain

Pulmonary Causes

• Pulmonary embolism (PE):

  • Most common serious cause (5-21% of cases) 1
  • Often presents with dyspnea followed by pleuritic chest pain 3
  • Pain is usually caused by pleural irritation due to distal emboli causing pulmonary infarction 3
  • Approximately 75% of patients with PE and pleural effusion have pleuritic chest pain 4
  • Most common cause of pleuritic chest pain and pleural effusion in patients under 40 years old 4

• Pneumonia:

  • Presents with localized pleuritic pain and often a friction rub 2
  • Respiratory infection with pneumonia rarely poses difficult diagnostic problems 5
  • Pain is typically associated with fever and productive cough 6

• Pneumothorax:

  • Characterized by acute chest pain and dyspnea 2
  • Primary spontaneous pneumothorax presents with sudden onset of pleuritic pain 5
  • Unilateral absence of breath sounds is a key physical finding 2

• Viral pleurisy:

  • Among the most common causes of pleurisy 6
  • Common viral agents include coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus 1

Cardiac Causes

• Pericarditis:

  • Pain typically increases in supine position 2
  • May be associated with a pericardial friction rub 2
  • Classically presents with chest pain that is sharp, pleuritic, and may improve by sitting up or leaning forward 3
  • Widespread ST-elevation with PR depression is the electrocardiographic hallmark 3

• Myocardial infarction:

  • Can occasionally present with pleuritic features 2
  • About 13% of patients with pleuritic pain may have acute myocardial ischemia 2
  • Retrosternal angina-like chest pain may reflect right ventricular ischemia in cases of PE 3

Other Causes

• Asbestos-related pleural disease:

  • Can cause acute pleural effusion with fever and severe pleuritic pain 3
  • Chronic severe pleuritic pain is rare in asbestos-related pleural disease 3
  • Pleural plaques are the most common manifestation of asbestos exposure 3

• Musculoskeletal causes:

  • Pain reproducible with chest wall palpation suggests musculoskeletal origin 2
  • However, 7% of patients with reproducible pain on palpation may still have acute coronary syndrome 2

• Malignancy:

  • Lung cancer and mesothelioma can cause more constant pain unrelated to respiratory movements 5
  • Pleural extension of pulmonary malignancy may mimic benign pleuritic pain 3

Diagnostic Approach

• History, physical examination, and chest radiography are recommended for all patients with pleuritic chest pain 6
• Electrocardiography is helpful, especially if there is clinical suspicion of myocardial infarction, PE, or pericarditis 6
• For suspected PE, validated clinical decision rules should guide the use of additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography 1
• D-dimer testing is a good screen for pulmonary emboli; if positive, spiral computed tomography should be obtained to confirm the diagnosis 4

Management Considerations

• Treatment is guided by the underlying diagnosis 1
• Nonsteroidal anti-inflammatory drugs are appropriate for pain management in those with virally triggered or nonspecific pleuritic chest pain 1, 6
• In patients with persistent symptoms, smokers, and those older than 50 years with pneumonia, radiographic resolution should be documented with repeat chest radiography six weeks after initial treatment 1