What are the causes and treatments of pleuritic chest pain?

Pleuritic Chest Pain: Causes and Approach

Definition and Key Characteristics

Pleuritic chest pain is sharp, stabbing, or "knifelike" pain that worsens with deep breathing, coughing, or respiratory movements, and is caused by inflammation or irritation of the pleura. 1

• The pain is typically localized and may be described as burning or stabbing in quality 1
• Distinguished from anginal pain, which presents as pressure or heaviness rather than sharp stabbing 1
• Pain reproducible with chest wall palpation suggests musculoskeletal origin, but 7% of patients with reproducible tenderness still have acute coronary syndrome 2

Life-Threatening Causes (Must Exclude First)

Pulmonary Embolism

• Most common serious cause, found in 5-21% of patients presenting with pleuritic chest pain 3
• Presents with dyspnea, pleuritic pain, tachycardia (>90% of cases), and tachypnea 2
• Pleural effusion develops in 46% of PE cases and is frequently hemorrhagic 1, 4
• Pleuritic chest pain occurs in approximately 75% of PE patients and is caused by pleural irritation from distal emboli causing alveolar hemorrhage 1, 5
• Central PE may present with retrosternal angina-like pain reflecting right ventricular ischemia 1

Acute Coronary Syndrome

• 13% of patients with pleuritic pain have acute myocardial ischemia 1, 2
• Atypical presentations including pleuritic pain are more common in elderly, women, diabetics, and those with renal insufficiency 6
• Sharp, pleuritic features do not exclude cardiac ischemia 2

Pneumothorax

• Classic triad: dyspnea, pleuritic pain on inspiration, and unilateral absence of breath sounds with hyperresonant percussion 2
• Presents with acute dyspnea and differential breath sounds 6

Aortic Dissection

• Sudden onset "ripping" chest pain radiating to the back 2
• Pulse differential in 30% of cases, BP difference ≥15 mm Hg between arms, or aortic regurgitation murmur 6

Pericarditis

• Sharp, pleuritic pain that improves when sitting forward and worsens when supine 2, 7
• ECG hallmark: widespread ST-elevation with PR depression 1, 2
• Pericardial friction rub may be audible (biphasic sound during inspiration and expiration) 1

Common Pulmonary Causes

Pneumonia

• Localized pleuritic pain with fever, productive cough, regional dullness to percussion, and egophony 2
• May present with pleural friction rub (sounds like creaking leather or walking on fresh snow) 1
• Sharp chest pain persisting after pneumonia requires urgent evaluation for empyema (occurs in up to 10% of bacteremic pneumococcal pneumonia), pericarditis, or other metastatic infections 1

Viral Pleurisy

• Among the most common causes of pleurisy after life-threatening conditions are excluded 8
• Common viral pathogens: Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus 3

Pleural Effusion

• May cause ongoing pleuritic discomfort 1
• Unilateral decreased breath sounds suggest large pleural effusion or pneumothorax 2

Musculoskeletal Causes

Costochondritis/Tietze Syndrome

• Tenderness of costochondral joints on palpation is the hallmark finding 9
• Pain exacerbated by deep breathing, coughing, or movement 9
• Critical caveat: 7% of patients with reproducible chest wall pain still have acute coronary syndrome 2

Other Important Causes

Herpes Zoster

• Pain in dermatomal distribution triggered by touch with characteristic unilateral dermatomal rash 2

Asbestos-Related Pleural Disease

• Can cause acute pleural effusion with fever and severe pleuritic pain 1, 2

Malignancy

• Pleural extension of pulmonary malignancy or mesothelioma may present with constant pain unrelated to respiratory movements 2

Diagnostic Approach

Immediate Evaluation (All Patients)

• ECG within 10 minutes of arrival to identify STEMI, pericarditis patterns, or signs of PE 2
• Chest X-ray to evaluate for pneumothorax, pneumonia, pleural effusion, or widened mediastinum 6, 2
• Cardiac troponin measured as soon as possible to exclude myocardial injury 2
• Vital signs assessment: tachycardia and tachypnea present in >90% of PE cases 2

Risk Stratification for Pulmonary Embolism

• Use validated clinical decision rules to determine pretest probability 2
• D-dimer testing with age- and sex-specific cutoffs for low-to-intermediate pretest probability patients 2
• CTA with PE protocol for stable patients with high clinical suspicion 2

Additional Testing When Indicated

• Transthoracic echocardiography if hemodynamic disturbances or new murmurs are present 6
• CMR with gadolinium to distinguish myopericarditis from other causes when myocardial injury is present with nonobstructive coronary arteries 2
• Blood gas determination from arterial blood, clinical chemistry (Hb, RBC, WBC, platelets, CRP, CK, CK-MB, troponin, creatinine) 6

Physical Examination Pearls

• Pleural friction rub: biphasic, coarse, grating sound heard during both inspiration and expiration, not cleared by coughing, indicates pleural inflammation 1
• Pericardial friction rub suggests pericarditis 6
• Unilateral decreased breath sounds suggest pneumothorax or large pleural effusion 2
• Pulsus paradoxus may indicate cardiac tamponade 6

Critical Pitfalls to Avoid

• Never assume reproducible chest wall tenderness excludes serious pathology (7% have ACS) 2
• Nitroglycerin response should not be used as diagnostic criterion - relief does not confirm or exclude myocardial ischemia 2
• Do not delay transfer for troponin testing in office settings - patients with suspected ACS should be transported urgently to ED by EMS 2
• Sharp, pleuritic pain does not exclude cardiac ischemia 2
• For persistent pain after pneumonia, repeat chest radiograph is mandatory to rule out empyema or other complications 1
• In patients >50 years, smokers, or those with persistent symptoms after pneumonia, document radiographic resolution with repeat chest X-ray six weeks after initial treatment 3

Treatment Principles

General Pain Management

• NSAIDs are appropriate for pain management in virally triggered or nonspecific pleuritic chest pain 8, 3
• Colchicine added to NSAIDs for pericarditis, with glucocorticoids reserved for refractory cases 7

Cause-Specific Treatment

• Pulmonary embolism: anticoagulation (bloody pleural fluid is not a contraindication) 4
• Empyema: drainage and antibiotics 1
• Pneumothorax: depends on size and clinical stability
• Treatment otherwise targeted at underlying cause 8