Intermittent Mid Upper Back Pleuritic Pressure: Differential Diagnosis and Management
The most critical priority is to exclude pulmonary embolism, which presents with pleuritic chest pain in 5-21% of emergency department cases and represents the most common serious cause that requires immediate evaluation. 1
Immediate Risk Stratification
Rule out life-threatening causes first using a validated clinical decision rule for pulmonary embolism, along with assessment for myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax through history, physical examination, electrocardiography, troponin assays, and chest radiography. 1
Key Clinical Features to Assess
Risk factors for pulmonary embolism: The presence or absence of venous thromboembolism risk factors is crucial, as pulmonary embolism can present with intermittent pleuritic pain even when initial chest radiograph, ECG, and arterial blood gases are normal. 2, 3
Pattern of pain: Pleuritic pain that is sharp, stabbing, or burning and worsens with inspiration suggests pleural irritation from various causes. 1
Associated symptoms: Fever suggests infectious etiology (viral pleuritis, pneumonia), while dyspnea or hypoxemia raises concern for pulmonary embolism or other cardiopulmonary pathology. 4, 5
Diagnostic Algorithm
First-Line Investigations
Chest radiography (PA and lateral): Essential initial test, though normal imaging does not exclude pulmonary embolism. 1, 3
D-dimer assay: Use in conjunction with validated clinical decision rules to guide further testing for pulmonary embolism. 2, 1
ECG and troponin: To exclude cardiac causes including myocardial infarction and pericarditis. 1
Advanced Imaging When Indicated
CT pulmonary angiography or ventilation/perfusion scanning: Required when pulmonary embolism cannot be excluded clinically. Ventilation/perfusion scanning may be preferred in certain contexts. 2, 6, 3
Echocardiography: Indicated for unexplained dyspnea to detect cardiovascular complications, particularly in patients with suspected pulmonary hypertension. 6
Thoracic ultrasound: More accurate than plain radiography for detecting pleural effusion and can guide thoracentesis if fluid is present. 7
Common Causes by Category
Life-Threatening (Exclude First)
Pulmonary embolism: Can present with intermittent pleuritic pain, particularly from distal emboli causing pleural irritation. Initial investigations may be normal. 2, 4, 1
Myocardial infarction and aortic dissection: Must be excluded with ECG, troponin, and appropriate imaging. 1
Infectious Causes
Viral pleuritis: Common cause with viruses including Coxsackievirus, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus. COVID-19 can also present initially as viral pleurisy. 1, 5
Pneumonia: Should be identified promptly and treated to prevent complications. 6, 1
Musculoskeletal Causes
- Costochondritis or rib subluxation: Particularly in patients with undiagnosed scoliosis, which can cause pin-point tenderness at costo-sternal joints with referred pain to the back. Thorough physical examination of anterior and posterior chest wall is essential. 8
Other Considerations
- Pleural effusion: If present, requires thoracentesis for diagnostic evaluation including pleural fluid analysis for appearance, biochemistry, cell count, Gram stain, culture, and cytology. 2, 7
Treatment Approach
When Serious Causes Are Excluded
NSAIDs are appropriate for pain management in patients with virally-triggered or nonspecific pleuritic chest pain. 1
Specific Treatments Based on Etiology
Pulmonary embolism: Immediate anticoagulation with heparin (loading dose 5,000-10,000 units followed by 400-600 units/kg daily as continuous infusion), titrated to maintain APTT at 1.5-2.5 times control values. 2
Pneumonia: Antibiotics with documentation of radiographic resolution at six weeks, particularly in smokers and patients over 50 years. 1
Viral pleuritis: Supportive management with NSAIDs for symptom relief. 1, 5
Critical Pitfalls to Avoid
Do not dismiss pleuritic pain with normal initial investigations: Pulmonary embolism can present with normal chest radiograph, ECG, and arterial blood gases. 3
Do not confuse different etiologies: For example, pancreaticopleural fistula requires completely different management than malignant effusion and should never receive pleurodesis. 9
Do not use oxygen alone for hypoventilation: Requires ventilatory support, not just supplemental oxygen. 2
Consider atypical presentations: COVID-19 and other conditions may present with pleuritic pain as the initial or sole manifestation. 5