Differential Diagnosis for Pleuritic Chest Pain
Life-Threatening Causes (Rule Out First)
Pulmonary embolism is the most common serious cause of pleuritic chest pain, occurring in 5-21% of emergency department presentations, and must be excluded before considering benign etiologies 1, 2, 3.
Critical Diagnoses to Exclude Immediately:
Pulmonary Embolism: Presents with dyspnea (in >90% of cases) followed by pleuritic chest pain, tachycardia, and tachypnea; pain results from pleural irritation due to distal emboli causing pulmonary infarction 4, 5, 1
Pneumothorax: Classic triad of dyspnea, pleuritic pain on inspiration, and unilateral absence of breath sounds with hyperresonant percussion 4, 6
Acute Coronary Syndrome: While typically presenting as pressure-type pain, 13% of patients with pleuritic pain may have acute myocardial ischemia 5
Aortic Dissection: Sudden onset "ripping" chest pain radiating to back, with pulse differential in 30% of cases 4
Pericarditis: Sharp, pleuritic pain that improves sitting forward and worsens supine, with friction rub and widespread ST-elevation with PR depression on ECG 4, 5
Esophageal Rupture: Severe pain with abrupt onset, emesis, subcutaneous emphysema, and pneumothorax in 20% 4
Common Pulmonary Causes
Pneumonia: Localized pleuritic pain with fever, productive cough, regional dullness to percussion, egophony, and possible friction rub 4, 5
Viral Pleurisy: Among the most common causes after life-threatening conditions are excluded; causative agents include Coxsackieviruses, RSV, influenza, parainfluenza, mumps, adenovirus, CMV, and EBV 1, 2
Pleural Effusion: May develop in 46% of PE cases and can cause ongoing pleuritic discomfort 5
Musculoskeletal Causes
- Costochondritis/Tietze Syndrome: Tenderness of costochondral joints on palpation; however, 7% of patients with reproducible chest wall pain may still have acute coronary syndrome 4, 5
Other Causes
Herpes Zoster: Pain in dermatomal distribution triggered by touch, with characteristic unilateral dermatomal rash 4
Myocarditis: Fever, chest pain, heart failure signs, S3 gallop 4
Asbestos-Related Pleural Disease: Can cause acute pleural effusion with fever and severe pleuritic pain 5
Malignancy: Pleural extension of pulmonary malignancy or mesothelioma may present with constant pain unrelated to respiratory movements 5, 7
Initial Diagnostic Approach
Obtain ECG within 10 minutes of arrival and chest radiography for all patients with pleuritic chest pain 4.
Essential Initial Testing:
ECG: Mandatory within 10 minutes to identify STEMI, pericarditis patterns, or signs of PE (S1Q3T3 pattern) 4
Chest X-ray: Evaluate for pneumothorax, pneumonia, pleural effusion, or widened mediastinum 4, 6
Cardiac Troponin: Measure as soon as possible in acute presentations to exclude myocardial injury 4
Validated Clinical Decision Rules: Use for pulmonary embolism (Wells criteria, PERC rule) to guide d-dimer testing, V/Q scanning, or CT angiography 2
Physical Examination Pearls:
Pleural Friction Rub: Biphasic sound (inspiration and expiration) like "creaking leather" or "walking on fresh snow," louder than crackles, not cleared by coughing, indicates pleural inflammation 5
Vital Signs: Tachycardia and tachypnea present in >90% of PE cases 4
Unilateral Decreased Breath Sounds: Suggests pneumothorax or large pleural effusion 4, 6
Critical Pitfalls to Avoid
Do not assume reproducible chest wall tenderness excludes serious pathology: 7% of patients with palpable tenderness have ACS 5
Do not use nitroglycerin response as a diagnostic criterion: Relief with nitroglycerin does not confirm or exclude myocardial ischemia 4
Do not delay transfer for troponin testing in office settings: Patients with suspected ACS should be transported urgently to ED by EMS 4
Sharp, pleuritic pain does not exclude cardiac ischemia: Sharp chest pain that increases with inspiration makes ischemic heart disease less likely but does not completely rule it out 4, 5