What are the symptoms and treatment options for pleuritis?

Pleuritis Symptoms and Treatment

Clinical Presentation

Pleuritic chest pain is the hallmark symptom of pleuritis, characterized by sudden, sharp, stabbing, or burning pain in the chest that intensifies with breathing, coughing, or movement. 1

Key Symptoms

• Pleuritic chest pain: Sharp, stabbing pain that worsens with inspiration and expiration 1
• Fever: Invariably present in infectious pleuritis, though may be masked by antipyretics 2
• Respiratory symptoms: Cough (often productive), dyspnea, and respiratory splinting to minimize pain 2, 3
• Physical examination findings: Unilateral decreased chest expansion, dullness to percussion, reduced or absent breath sounds, and possible scoliosis 4
• Associated symptoms: Headaches, referred abdominal pain, chills, and night sweats may occur 2, 3
• Positional preference: Patients often lie on the affected side to splint the hemithorax 4

Critical Warning Signs

Patients remaining febrile or unwell 48 hours after pneumonia treatment require active exclusion of parapneumonic effusion through repeat chest radiography 4. Rapid progression can occur—"explosive pleuritis" may develop a massive effusion occupying >90% of the hemithorax within 24 hours 5.

Diagnostic Approach

Perform diagnostic thoracentesis within 24 hours if pleural infection is suspected, as this guides antibiotic selection and determines drainage necessity. 6, 7

Essential Investigations

• Ultrasound: Preferred initial imaging to confirm effusion and guide thoracentesis 6, 7
• Pleural fluid analysis: Measure pH using blood gas analyzer (not litmus paper), glucose, LDH, protein, and obtain cultures 2, 7
• Blood cultures: Obtain in all suspected parapneumonic effusions 7
• CT scanning: Provides comprehensive assessment when ultrasound inadequate or complications suspected 6

Drainage Indications

Drain any parapneumonic effusion with pH <7.2, visible pus, positive Gram stain/culture, or loculations present 2, 4. Small effusions (<10mm rim) can be treated with antibiotics alone 4.

Treatment Strategy

Infectious Pleuritis

All patients must receive antibiotics immediately upon identification of pleural infection, with regimen selection based on acquisition setting. 2, 7

Community-Acquired Infection

• First-line: Cefuroxime 1.5g IV three times daily PLUS metronidazole 400mg orally three times daily 7
• Alternative: Amoxicillin 1g three times daily plus clavulanic acid 125mg three times daily 2
• Alternative: Clindamycin 300mg four times daily (combines appropriate spectrum in single agent) 2
• Metronidazole is essential for anaerobic coverage, particularly with aspiration risk 7

Hospital-Acquired Infection

• First-line: Piperacillin-tazobactam 4.5g IV four times daily 2, 7
• Alternatives: Ceftazidime 2g three times daily IV or meropenem 1g three times daily IV 2

Critical Antibiotic Considerations

• Avoid aminoglycosides: Poor pleural space penetration and inactive in acidic pleural fluid 2, 7
• Never administer antibiotics directly into pleural space: Unnecessary due to good penetration of beta-lactams and cephalosporins 2
• Duration: Continue oral antibiotics at discharge for 1-4 weeks, longer if residual disease present 7

Drainage Procedures

Initial drainage should use small-bore chest tubes (14F or smaller) inserted under ultrasound guidance. 6, 7

• Insert chest tube at outset for enlarging effusions or those compromising respiratory function rather than repeated thoracentesis 7
• If tube becomes blocked, flush with 20-50ml normal saline and check position with imaging 2
• Do not use early VATS or thoracotomy as initial treatment over chest tube drainage 7

Management of Persistent Collections

For residual collections after initial drainage, use combination tissue plasminogen activator (TPA) 10mg twice daily PLUS DNase 5mg twice daily for 3 days. 6, 7

• Obtain patient consent due to bleeding risk 7
• Reduce TPA dose in patients on anticoagulation 7
• This combination is superior to either agent alone 6, 7

Surgical Intervention

Consider surgical referral if no improvement after 5-7 days of appropriate antibiotics and drainage. 6, 7

• VATS is preferred over thoracotomy, resulting in shorter hospital stays, less postoperative pain, and fewer complications 6, 7
• Ensure respiratory physician or thoracic surgeon involvement for all patients requiring chest tube drainage 2
• Organized empyema with thick fibrous peel may require formal thoracotomy and decortication 2

Non-Infectious Inflammatory Pleuritis

• Rheumatoid pleuritis: Disease-modifying antirheumatic drugs 6
• Lupus pleuritis: Corticosteroids and immunosuppressive agents; decortication may be viable for refractory cases 8
• Malignant pleuritis: Treat primary malignancy and consider pleurodesis for recurrent effusions 6

Symptomatic Management

Pain Control

Adequate analgesia is essential to maintain comfort, facilitate deep breathing, and prevent secondary scoliosis. 2

• NSAIDs are appropriate for virally-triggered or nonspecific pleuritic chest pain 1
• Intrapleural bupivacaine 0.25% (0.5-1.0 ml/kg) can be instilled if fibrinolytic agents cause discomfort 2
• Chest drains can be uncomfortable; soft pigtail catheters minimize discomfort unless pulling occurs from stitches or tape 2

Antipyretics and Supportive Care

• Antipyretics should be given for comfort, though caution necessary as fever indicates clinical progress 2
• Early mobilization and exercise recommended, even with drain in situ 2
• Chest physiotherapy is not beneficial and should not be performed 2
• Ensure adequate nutritional support commencing as soon as possible 2

Follow-Up and Monitoring

Assess effectiveness of drainage and resolution of fever/sepsis 5-8 days after initiating chest tube drainage and antibiotics, documenting response in clinical notes. 2, 6, 7

Ongoing Assessment

• Regular monitoring of fever, inflammatory markers, and symptoms 6, 7
• Follow-up imaging to ensure resolution and absence of loculations 6, 7
• Consider surgical consultation if drainage ineffective or clinical improvement not achieved within 7 days 6, 7

Long-Term Surveillance

Extended follow-up is crucial for nonspecific pleuritis, as up to 15% subsequently develop pleural malignancy. 6, 7

• Long-term radiological monitoring recommended where malignancy suspected but initial biopsies negative 6
• In patients with persistent symptoms, smokers, and those >50 years with pneumonia, document radiographic resolution with repeat chest radiography six weeks after initial treatment 1

Critical Pitfalls to Avoid

• Delayed drainage: Increases morbidity, hospital stay, and possibly mortality 7
• Misdiagnosis: Rheumatoid effusion, malignancy, and mesothelioma can mimic parapneumonic effusion with low pH and loculations 6, 7
• Inadequate analgesia: Interferes with deep breathing and coughing, potentially worsening outcomes 2
• Secondary thrombocytosis: Common (93% of pediatric empyema cases) but benign; antiplatelet therapy not necessary 2
• Atypical presentations: COVID-19 and other viral infections may present with pleuritic pain as initial manifestation 9