What are the signs and symptoms of pleurisy?

Signs and Symptoms of Pleurisy

Pleurisy presents with sharp, stabbing, or "knifelike" chest pain that characteristically worsens with deep breathing, coughing, or other respiratory movements, and is often accompanied by dyspnea. 1

Primary Clinical Features

Pain Characteristics

• Sharp, stabbing, or burning quality that is localized and intensifies during inspiration, coughing, or chest movement 1, 2
• Pain may be described as "knifelike" and is typically unilateral 1
• Patients often exhibit respiratory splinting (lying on the affected side to limit chest wall movement and reduce pain) 3
• The pleuritic nature distinguishes it from anginal pain, which is usually described as pressure or heaviness rather than sharp or stabbing 1

Respiratory Symptoms

• Dyspnea (shortness of breath) is commonly present alongside chest pain 3
• Cough, which may be dry or productive 3, 2
• Patients may demonstrate tachypnea (rapid breathing) 3

Constitutional Symptoms

• Fever is frequently present, particularly in infectious causes 3
• Chills and night sweats may occur 3
• Fatigue, weakness, or malaise 3
• Weight loss and anorexia in chronic cases 3

Physical Examination Findings

Auscultatory Signs

• Pleural friction rub is a hallmark finding when present, described as a coarse, grating, creaking sound resembling "walking on fresh snow" or "creaking leather" 3, 1
• The friction rub is biphasic (heard during both inspiration and expiration) and does not clear with coughing 1
• Reduced or absent breath sounds over the affected area, particularly if pleural effusion is present 3

Percussion and Palpation Findings

• Dullness to percussion over areas of pleural effusion 3, 4
• Decreased chest expansion on the affected side 3
• Scoliosis may develop in some cases 3

Associated Signs

• Pleural effusion is often present on examination and imaging 3
• Cyanosis may occur due to ventilation-perfusion mismatch 3
• Hypoxemia with oxygen saturation below 92% indicates severe disease 3

Important Clinical Pitfalls

Do Not Rely on Symptoms Alone

• Symptoms and examination findings are not specific to pleurisy and cannot rule out serious underlying conditions 3
• Pain reproducible with chest wall palpation suggests musculoskeletal origin but does not exclude serious pathology—7% of patients with reproducible pain on palpation have acute coronary syndrome 1

Life-Threatening Causes Must Be Excluded First

• Pulmonary embolism is found in 5-21% of patients presenting with pleuritic chest pain and must be ruled out 5, 2
• Other serious causes requiring exclusion include myocardial infarction (13% of patients with pleuritic pain have acute myocardial ischemia), pericarditis, pneumothorax, and aortic dissection 1, 2
• Empyema occurs in up to 10% of patients with bacteremic pneumococcal pneumonia and requires urgent evaluation 1

Special Considerations

• In children with pneumonia who remain febrile or unwell 48 hours after admission, re-evaluation with repeat chest radiograph is mandatory to assess for parapneumonic effusion or empyema 3
• Asbestos-related pleural disease can cause acute pleural effusion with severe pleuritic pain and fever, often discovered incidentally on radiographs 3
• Chronic severe pleuritic pain is rare but when present may be disabling and bilateral, often following pleural effusions 3