What causes sharp chest pain after pneumonia?

Sharp Chest Pain After Pneumonia

Sharp chest pain following pneumonia most commonly indicates pleural inflammation (pleurisy) from the infection itself, but you must urgently rule out serious complications including empyema, pulmonary embolism, pericarditis, or pneumothorax before attributing it to benign post-infectious inflammation. 1

Understanding the Pain Character

Sharp, pleuritic chest pain is characterized by:

• Stabbing or "knifelike" quality that worsens with deep breathing, coughing, or respiratory movements 2
• Localized to the affected area rather than diffuse 1, 2
• Caused by pleural inflammation or irritation from the pneumonia 2, 3

This differs from cardiac chest pain, which typically presents as pressure or heaviness rather than sharp stabbing pain 1.

Critical Complications to Rule Out Immediately

Life-Threatening Causes Requiring Urgent Evaluation

Empyema (infected pleural fluid):

• Occurs in up to 10% of patients with bacteremic pneumococcal pneumonia 1
• Order repeat chest radiograph and possibly CT scan for any patient with inadequate clinical response to pneumonia treatment 1
• Sample and culture any pleural fluid, analyzing for cell count and chemistry 1

Pulmonary Embolism:

• PE is the most common serious cause of pleuritic chest pain, found in 5-21% of patients presenting with this symptom 4
• Pneumonia can mask PE, particularly when systemic symptoms like fever predominate 5, 6
• Consider PE especially if: initial improvement with antibiotics followed by worsening condition, persistent pleuritic pain despite treatment, or breathlessness on exertion 5
• Pleuritic chest pain from PE occurs in approximately 52% of cases due to pleural irritation from distal emboli causing alveolar hemorrhage 2

Pneumothorax:

• Presents with dyspnea and pleuritic pain with unilateral absence of breath sounds 2
• Requires immediate chest radiograph 1

Pericarditis:

• Up to 10% of bacteremic pneumococcal pneumonia can have metastatic pericarditis 1
• Pain typically increases when lying supine and may improve sitting forward 2
• May require echocardiogram to rule out 1

Other metastatic infections:

• Bacteremic pneumococcal pneumonia can cause meningitis, arthritis, endocarditis, and peritonitis 1

Non-Infectious Complications

Cardiovascular complications that can present with chest pain after pneumonia:

• Acute myocardial infarction 1
• Heart failure 1
• Pulmonary embolus with infarction 1

Diagnostic Approach

Physical Examination Findings

Listen for pleural friction rub:

• Sounds like "creaking leather or walking on fresh snow" 2
• Coarse, grating, creaking quality, louder than crackles 2
• Biphasic (heard during both inspiration and expiration), not cleared by coughing 2
• Indicates pleural inflammation commonly associated with pneumonia with pleural involvement 2

Essential Testing

For persistent or worsening pain after pneumonia:

• Repeat chest radiograph (mandatory) 1
• CT scan if pleural fluid suspected or inadequate response to therapy 1
• Use validated clinical decision rules for PE to guide d-dimer, V/Q scan, or CT angiography 4
• Troponin assays and ECG to exclude myocardial infarction 4

Common Pitfalls to Avoid

Do not assume all post-pneumonia chest pain is benign pleurisy:

• PE can be masked by pneumonia, especially when fever and systemic symptoms predominate 5, 6
• Initial improvement followed by clinical worsening should raise suspicion for PE or other complications 5
• Normal D-dimer and absence of DVT on Doppler do not completely exclude PE 6

Do not rely on pain relief with nitroglycerin as diagnostic:

• Relief with nitroglycerin is not specific for cardiac ischemia and can occur with esophageal spasm 1

Treatment Based on Cause

For Benign Post-Infectious Pleurisy

NSAIDs are appropriate for pain management in virally-triggered or nonspecific pleuritic chest pain 4

• Ibuprofen can be used at the lowest effective dose for the shortest duration needed 7

For Complications

Treatment is guided by the specific underlying diagnosis identified through the evaluation above 4:

• Empyema requires drainage and antibiotics 1
• PE requires anticoagulation 5, 6
• Other complications require targeted therapy

Follow-Up Imaging

In patients with persistent symptoms, smokers, and those over 50 years with pneumonia, document radiographic resolution with repeat chest radiography six weeks after initial treatment 4