What is the role of steroids, such as prednisone, in the treatment of viral pleurisy?

Steroids Are Not Recommended for Viral Pleurisy

Corticosteroids should not be used routinely in the treatment of viral pleurisy as they may exacerbate the infection and increase mortality rates. 1

Evidence Against Corticosteroid Use in Viral Pleurisy

• Studies on influenza-related viral pneumonia have found that corticosteroids can worsen the infection and increase mortality rates 1
• The use of corticosteroids for viral pneumonia is not recommended unless in a clinical trial or if steroids are indicated for another condition 1
• There is no evidence from randomized controlled trials to support specific drug treatment, including corticosteroids, against viral infections such as coronavirus 1
• Systemic use of glucocorticoids needs to be approached with caution, with evidence not supporting routine use 1

Specific Guidance for Viral Pleural Effusions

• Based on randomized clinical trials and systematic reviews, there is no evidence to support the routine use of adjunctive corticosteroids in patients with viral pleurisy 1
• In tuberculous pleurisy (which may present similarly), four prospective, double-blind, randomized studies showed that prednisone administration did not confer a beneficial effect on residual pleural thickening or prevention of other long-term pleural sequelae 1
• Multiple studies have demonstrated no significant difference in clinical outcomes, rate of reabsorption of pleural fluid, pleural sequelae, or lung capacity between corticosteroid and placebo groups in pleural effusions 2, 3

Management Approach for Viral Pleurisy

• Supportive care is the mainstay of treatment for viral pleurisy 1
• For patients with pleural effusions, drainage of the effusion (when indicated) is more important than medication for symptomatic improvement 2
• Vital observations including heart rate, respiration rate, and oxygen saturation should be closely monitored 1
• Symptomatic treatment of fever with antipyretics such as ibuprofen when temperature exceeds 38.5°C 1

Potential Risks of Corticosteroid Use in Viral Infections

• Increased risk of viral replication and delayed viral clearance 1
• Potential for secondary bacterial infections due to immunosuppression 1
• In HIV-associated pleural effusions, prednisolone use has been associated with a significantly higher incidence of Kaposi sarcoma 4
• Meta-analyses in influenza patients show increased mortality with corticosteroid use 1

Special Considerations

• While corticosteroids are not recommended for viral pleurisy, they may have a role in specific conditions:
  • Severe COVID-19 pneumonia requiring oxygen or mechanical ventilation (using dexamethasone 6 mg daily for up to 10 days) 5
  • Severe community-acquired pneumonia with septic shock refractory to fluid resuscitation and vasopressor use, especially with elevated CRP >150 mg/L 1, 5

Practical Management Algorithm

1. Confirm viral etiology of pleurisy through appropriate testing
2. Implement supportive care measures:
   • Adequate hydration and rest 1
   • Antipyretics for fever management 1
   • Oxygen therapy if hypoxemia is present 1
3. Consider drainage if significant pleural effusion is present 2, 6
4. Avoid corticosteroids unless specifically indicated for another condition 1
5. Monitor for clinical deterioration that might suggest bacterial superinfection, which would require antibiotic therapy 1