What is the diagnosis and management for pleuritic chest pain without respiratory symptoms and a negative chest X-ray?

Pleuritic Chest Pain Without Respiratory Symptoms and Negative Chest X-Ray

In a patient with isolated pleuritic chest pain, no respiratory symptoms, and a negative chest X-ray, the most likely diagnosis is musculoskeletal chest pain (particularly costochondritis), but you must systematically exclude life-threatening cardiac causes—specifically pericarditis and acute coronary syndrome—before attributing symptoms to a benign etiology. 1, 2

Immediate Diagnostic Workup

Essential Initial Testing

• Obtain an ECG within 10 minutes to identify pericarditis patterns (widespread ST-elevation with PR depression), signs of pulmonary embolism, or acute coronary syndrome 2
• Measure cardiac troponin as soon as possible to exclude myocardial injury, even though the presentation seems non-cardiac 2
• The chest X-ray is already negative, which reduces likelihood of pneumothorax, pneumonia, or pleural effusion, but does not exclude cardiac causes 2

Critical Diagnostic Considerations

Pericarditis remains a key concern despite the negative chest X-ray:

• Characterized by sharp, pleuritic pain that improves when sitting forward and worsens when supine 2
• ECG shows widespread ST-elevation with PR depression 2
• Obtain transthoracic echocardiography (TTE) to determine presence of pericardial effusion or ventricular wall motion abnormalities 2
• If diagnostic uncertainty exists, CMR with gadolinium is useful to determine extent of pericardial inflammation 2

Acute coronary syndrome can present with pleuritic pain in 13% of patients 2:

• Do not assume sharp, pleuritic pain excludes cardiac ischemia—it makes ischemic heart disease less likely but does not rule it out 2
• Troponin measurement is essential even when musculoskeletal pain seems likely 2

Common Pitfalls to Avoid

• Never assume reproducible chest wall tenderness excludes serious pathology: 7% of patients with palpable chest wall tenderness have acute coronary syndrome 2
• Do not use nitroglycerin response as a diagnostic criterion: relief with nitroglycerin does not confirm or exclude myocardial ischemia 2
• Do not dismiss the complaint based on negative chest X-ray alone: chest X-ray has sensitivity of only 2-60% for certain conditions and can be normal in 11-62% of diaphragmatic injuries or uncomplicated hernias 1

Most Likely Diagnosis: Musculoskeletal Pain

If cardiac workup (ECG, troponin, and echocardiography) is negative:

Costochondritis is the most common cause:

• Characterized by tenderness of costochondral joints on palpation 3, 2
• Pain is sharp, localized, and reproducible with chest wall palpation 3
• Positional pain that changes with body position is reassuring 3

Management Algorithm

If Cardiac Testing is Negative:

• Treat as costochondritis with anti-inflammatory medications 4
• Provide reassurance and thorough explanation of the benign nature 3
• Follow until symptoms resolve 3

If Pericarditis is Confirmed:

• Anti-inflammatory medications 4
• Cardiology consultation 4

If Symptoms Persist Despite Negative Workup:

• Evaluate for gastrointestinal causes (esophageal reflux, esophageal dysmotility) if recurrent pain without cardiac or pulmonary cause 1
• Consider upper endoscopy if esophageal cause suspected 1
• Consider referral to cognitive-behavioral therapy for recurrent episodes without physiological cause 1, 4

When to Reconsider the Diagnosis

• If pain becomes constant and unrelated to respiratory movements, consider malignancy (pleural extension of pulmonary malignancy) 2
• If dermatomal distribution develops, consider herpes zoster 3, 2
• If symptoms worsen or new symptoms develop (fever, dyspnea, syncope), repeat evaluation for pneumonia, pulmonary embolism, or other serious causes 1, 3