From the Guidelines
Pleuritic chest pain is most commonly caused by pulmonary embolism, which occurs when a blood clot lodges in the lung's blood vessels, creating inflammation and pain, as supported by the most recent and highest quality study 1. The causes of pleuritic chest pain can be varied, but the most critical consideration is pulmonary embolism due to its potential for high morbidity and mortality.
Common Causes of Pleuritic Chest Pain
- Pulmonary embolism: This is a serious cause of pleuritic chest pain, occurring when a blood clot lodges in the lung's blood vessels, creating inflammation and pain 1.
- Respiratory infections: Infections like pneumonia, viral pleuritis, and bronchitis can trigger inflammation through direct infection or immune response.
- Pneumothorax: A collapsed lung causes sharp pain as air enters the pleural space.
- Autoimmune conditions: Conditions like lupus, rheumatoid arthritis, and inflammatory bowel disease can affect the pleura.
- Chest trauma: Trauma, including rib fractures, can cause pleuritic pain.
- Costochondritis: Inflammation of rib cartilage can cause pleuritic pain.
- Pericarditis: Inflammation of the heart sac can cause pleuritic pain.
- Certain cancers: Cancers that spread to the pleura can cause pleuritic pain.
Importance of Early Diagnosis
Early diagnosis and treatment of the underlying cause of pleuritic chest pain are crucial to prevent complications and improve quality of life. Pulmonary embolism, in particular, requires prompt diagnosis and treatment to prevent high morbidity and mortality, as highlighted in the study 1.
Clinical Presentation
Pleuritic chest pain typically worsens with breathing, coughing, or movement because these actions cause the inflamed pleural surfaces to rub against each other. A thorough clinical evaluation, including history, physical examination, and diagnostic tests, is essential to determine the underlying cause of pleuritic chest pain. The study 1 emphasizes the importance of evaluating the likelihood of pulmonary embolism in patients with pleuritic chest pain, given its high potential for morbidity and mortality.
From the Research
Causes of Pleuritic Chest Pain
Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling 2. The causes of pleuritic chest pain can be varied and include:
- Pulmonary embolism, which is the most common serious cause, found in 5% to 21% of patients who present to an emergency department with pleuritic chest pain 2
- Myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax, which are other serious causes that should be ruled out using history and physical examination, electrocardiography, troponin assays, and chest radiography 2
- Viruses, which are common causative agents of pleuritic chest pain, including Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus 2
- Primary spontaneous pneumothorax, which is characterized by acute chest pain 3
- Pulmonary hypertension, lung cancer, and mesothelioma, which show more constant pain unrelated to respiratory movements 3
- Acute exacerbation of chronic obstructive pulmonary disease (COPD), which can be differentiated by asking the patient if the pain is related to breathing 3
Diagnosis and Management
Diagnosis of pleuritic chest pain involves assessing the clinical probability of pulmonary embolism, using a structured score or clinical gestalt, and employing diagnostic tools such as D-dimer testing and chest imaging 4. Management of pleuritic chest pain is guided by the underlying diagnosis, with nonsteroidal anti-inflammatory drugs being appropriate for pain management in those with virally triggered or nonspecific pleuritic chest pain 2. In patients with pulmonary embolism, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran are noninferior for treating pulmonary embolism and have a lower rate of bleeding compared to heparin combined with a vitamin K antagonist 4, 5.