What is the appropriate evaluation and treatment for a 13-year-old with pleuritic chest pain that occurs only when breathing in?

Evaluation and Management of Pleuritic Chest Pain in a 13-Year-Old

In a 13-year-old with isolated pleuritic chest pain (pain only with breathing in), the most likely diagnosis is a benign musculoskeletal condition such as costochondritis, but you must systematically exclude life-threatening causes—particularly pneumothorax, pneumonia, and pericarditis—before reassuring the patient and family. 1

Initial Assessment Priority

Chest pain in children is rarely cardiac (only 1-5% of cases), but your evaluation must efficiently rule out dangerous causes through targeted history, physical examination, and selective testing rather than extensive workup. 1

Critical Red Flags to Assess Immediately

Ask specifically about these concerning features that would escalate urgency:

• Exertional component: Does pain occur during physical activity or emotional stress? (suggests cardiac ischemia) 1
• Syncope or presyncope: Any loss of consciousness or near-fainting with the pain? (warrants immediate cardiac evaluation) 1
• Palpitations: Sensation of irregular or racing heartbeat? 1
• Fever: Suggests infectious etiology like pneumonia or pericarditis 1
• Dyspnea beyond what pleuritic pain would cause: May indicate pneumothorax, pneumonia, or pulmonary embolism 1
• Sudden onset "ripping" pain: Though rare in pediatrics, consider aortic dissection 1

Reassuring Features (Suggests Benign Etiology)

• Fleeting pain lasting only seconds: Unlikely to be cardiac 1
• Sharp, localized pain that can be pointed to with one finger 1
• Positional pain that changes with body position 1
• Reproducible pain with chest wall palpation (though this does NOT completely exclude serious disease—7% of patients with reproducible tenderness have acute coronary syndrome in adults) 2

Physical Examination Essentials

Perform a focused examination looking for:

Vital Signs

• Temperature, heart rate, respiratory rate, blood pressure—tachycardia and tachypnea are present in >90% of pulmonary embolism cases 2, though PE is rare in this age group

Respiratory System

• Decreased breath sounds unilaterally: Suggests pneumothorax or large pleural effusion 2, 1
• Pleural friction rub: Biphasic creaking sound (like walking on fresh snow) heard during both inspiration and expiration, indicates pleural inflammation from pneumonia or pleuritis 2, 3
• Localized dullness to percussion with egophony: Suggests pneumonia 2

Cardiovascular System

• Pericardial friction rub: Indicates pericarditis 2
• Assess for murmurs, abnormal heart sounds, irregular rhythm 1

Musculoskeletal System

• Costochondral joint tenderness: Characteristic of costochondritis, the most common benign cause 2, 1
• Reproducible pain with palpation of chest wall 1

Diagnostic Testing Algorithm

Obtain Immediately if ANY Concern for Serious Etiology:

1. ECG within 10 minutes 2, 1

• Look for: STEMI patterns, widespread ST-elevation with PR depression (pericarditis), signs of right heart strain (pulmonary embolism)
• Critical point: Get the ECG even if you suspect musculoskeletal pain 1

2. Chest X-ray 2, 1

• Evaluates for: pneumothorax, pneumonia, pleural effusion, widened mediastinum
• Mandatory if respiratory symptoms (cough, dyspnea, fever) are present 1

Additional Testing Only if Indicated:

3. Cardiac troponin 2, 1

• Only if acute coronary syndrome is genuinely suspected (extremely rare in children)
• Do NOT delay transfer to emergency department for office-based troponin testing 1

4. Do NOT routinely order:

• Exercise stress testing (rarely changes management in pediatric chest pain) 1
• Extensive cardiac workup without clear indications 1
• Ambulatory ECG monitoring unless palpitations are present 1

Management Based on Findings

If Life-Threatening Causes Excluded and Examination Suggests Costochondritis:

Treatment approach:

• Pain management with NSAIDs 4, 5
• Reassurance with thorough explanation 1
• Take symptoms seriously while explaining the benign nature 1
• Follow-up until symptoms resolve 1

If Pneumonia Diagnosed:

• Appropriate antibiotics 1
• Follow until complete resolution 1
• Important: In patients with persistent symptoms after pneumonia treatment, obtain repeat chest X-ray to rule out empyema (occurs in up to 10% of bacteremic pneumococcal pneumonia) 3

If Pericarditis Suspected:

• Sharp pain that improves sitting forward, worsens supine 2
• ECG shows widespread ST-elevation with PR depression 2
• May require echocardiogram 3

If Anxiety/Psychogenic Cause Suspected:

• 81% of children with unexplained chest pain meet criteria for anxiety disorders 1
• Consider referral to cognitive-behavioral therapy if cardiac workup negative and pain persists 1
• Do NOT dismiss these causes—they are real and treatable 1

Critical Pitfalls to Avoid

1. Do NOT assume reproducible chest wall tenderness excludes serious pathology—7% of adults with palpable tenderness have acute coronary syndrome 2

2. Do NOT use nitroglycerin response as a diagnostic criterion—relief does not confirm or exclude ischemia 2

3. Do NOT delay emergency transfer for office-based testing if acute coronary syndrome suspected 2, 1

4. Sharp, pleuritic pain does NOT exclude cardiac ischemia—13% of patients with pleuritic pain have acute myocardial ischemia in adult studies 3

5. Do NOT order extensive cardiac testing without clear indications—this leads to unnecessary procedures and anxiety 1

When to Refer or Escalate

Immediate emergency department transfer if:

• Any concern for pneumothorax, pulmonary embolism, pericarditis, or cardiac ischemia
• Respiratory distress
• Signs of cardiac compromise
• Sudden onset severe pain with systemic symptoms 1

Consider underlying diagnoses if recurrent or persistent:

• Immunodeficiency
• Congenital anomalies 1