What is pleuritic chest pain?

What is Pleuritic Chest Pain?

Pleuritic chest pain is sharp, stabbing, or "knifelike" pain that worsens with breathing, coughing, or other respiratory movements, caused by inflammation or irritation of the pleura (the lining around the lungs). 1, 2

Key Defining Characteristics

• Pain quality: Sharp, stabbing, or burning sensation that is distinctly different from the pressure or heaviness of cardiac angina 2, 3
• Respiratory provocation: The hallmark feature is that the pain intensifies during deep breathing, coughing, or chest movement 1, 2
• Localization: Typically well-localized to a specific area of the chest wall, unlike the diffuse or radiating pattern of cardiac pain 2
• Duration: Can be brief episodes or persistent, depending on the underlying cause 3, 4

Clinical Significance: Not Always Benign

While pleuritic pain often suggests a non-cardiac cause, this is a dangerous assumption. The 2014 AHA/ACC guidelines explicitly warn that pleuritic features do NOT exclude acute coronary syndrome 1:

• 13% of patients presenting with pleuritic pain had acute myocardial ischemia 1, 2
• Even when chest pain is reproducible with palpation (suggesting musculoskeletal origin), 7% still had acute coronary syndrome 1, 2

Common Serious Causes to Rule Out

Life-Threatening Conditions

• Pulmonary embolism: The most common serious cause, found in 5-21% of emergency department presentations with pleuritic pain 3. Typically presents with dyspnea followed by pleuritic chest pain from pleural irritation due to distal emboli causing pulmonary infarction 2
• Pneumothorax: Presents with sudden dyspnea and pleuritic pain with unilateral absence of breath sounds 2
• Pericarditis: Sharp, pleuritic pain that typically improves by sitting up or leaning forward, with widespread ST-elevation and PR depression on ECG 2
• Pneumonia: May present with localized pleuritic pain and pleural friction rub 2

Other Important Causes

• Viral pleuritis: Common causative agents include Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, and Epstein-Barr virus 3
• Asbestos-related pleural disease: Can cause acute pleural effusion with fever and severe pleuritic pain, though this is rare 1

Physical Examination Findings

• Pleural friction rub: A coarse, grating, creaking sound (like walking on fresh snow) heard during both inspiration and expiration, indicating pleural inflammation 2
• The rub is biphasic, louder than crackles, and not affected by coughing 2

What Pleuritic Pain is NOT

The 2014 AHA/ACC guidelines clearly distinguish pleuritic pain from typical angina 1:

• Angina is deep, poorly localized chest or arm pain associated with exertion, relieved promptly (<5 minutes) with rest or nitroglycerin 1
• Angina is described as pressure or heaviness, not sharp or stabbing 2
• Pleuritic pain does not follow the typical anginal pattern of exertion-provocation and rest-relief 1

Critical Clinical Pitfall

Never dismiss pleuritic chest pain as automatically non-cardiac. The evidence shows a significant minority of patients with pleuritic features have life-threatening conditions including acute coronary syndrome 1, 2. Always maintain clinical suspicion for pulmonary embolism, which requires validated clinical decision rules (like Wells score) to guide further testing with d-dimer, ventilation-perfusion scans, or CT angiography 3, 5.