What is the cause of right-sided chest pain that worsens with deep breathing in a 21-year-old who vapes?

Right-Sided Chest Pain with Deep Breathing in a 21-Year-Old Who Vapes

In a 21-year-old with right-sided pleuritic chest pain, the most likely diagnoses are pneumothorax (especially given vaping history), viral pleurisy, or musculoskeletal pain—but you must immediately rule out pulmonary embolism, pneumonia, and pneumothorax before attributing symptoms to benign causes. 1, 2

Immediate Life-Threatening Conditions to Exclude First

Pneumothorax (High Priority in Vapers)

• Primary spontaneous pneumothorax characteristically presents with acute chest pain and is particularly relevant in young adults who vape 3
• Look for unilateral absence of breath sounds, dyspnea, and pain on inspiration 1
• Obtain chest X-ray immediately to confirm or exclude this diagnosis 1, 4
• Vaping has been associated with acute lung injury and increased pneumothorax risk, making this a critical consideration 3

Pulmonary Embolism

• PE is the most common serious cause of pleuritic chest pain, found in 5-21% of emergency department presentations 2
• Key features include tachycardia (>100 bpm) and dyspnea present in >90% of patients, plus pain with inspiration 1
• In a 21-year-old, assess for risk factors: recent immobilization, oral contraceptives, long flights, or family history 1, 2
• Use a validated clinical decision rule (Wells criteria or PERC rule) to guide D-dimer testing 4, 2

Pneumonia

• Fever, localized chest pain (may be pleuritic), regional dullness to percussion, and egophony suggest pneumonia 1, 4
• Chest X-ray confirms diagnosis 4, 2
• Vaping-associated lung injury can mimic pneumonia 3

Most Likely Benign Diagnoses

Viral Pleurisy

• Viruses are common causative agents of pleuritic chest pain, including Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, and adenovirus 2
• Presents with sharp, stabbing pain worsening with deep breathing 2
• Often follows or accompanies upper respiratory symptoms 3, 2
• Diagnosis is clinical after excluding serious causes 2

Musculoskeletal Pain (Costochondritis)

• Pain reproducible by palpation is more likely musculoskeletal than serious pathology 1, 4
• The American College of Cardiology states that chest tenderness on palpation or pain with inspiration markedly reduce the probability of acute coronary syndrome 1
• Systematic palpation of the costal margin can diagnose painful rib syndrome with high specificity 5

Diagnostic Algorithm

Step 1: Focused Physical Examination

• Perform focused cardiovascular and respiratory examination to identify complications 1
• Check vital signs: tachycardia, tachypnea, fever, hypoxemia 1
• Auscultate for unilateral absence of breath sounds (pneumothorax), crackles (pneumonia), or friction rub (pleurisy/pericarditis) 1, 3
• Palpate chest wall systematically for reproducible tenderness 1, 5, 4

Step 2: Immediate Testing

• Obtain chest X-ray to evaluate for pneumothorax, pneumonia, pleural effusion, or infiltrates 1, 4, 2
• ECG if any concern for cardiac causes (though extremely unlikely in a 21-year-old without exertional component) 1, 5
• Consider D-dimer only if clinical prediction rule suggests PE is possible 4, 2

Step 3: Risk Stratification

• If chest X-ray shows pneumothorax: immediate treatment (observation vs. chest tube depending on size) 1
• If pneumonia confirmed: initiate antibiotics and ensure radiographic resolution at 6 weeks, especially in those who vape 2
• If PE suspected based on clinical decision rule: proceed to CT angiography 1, 2
• If all serious causes excluded and physical exam negative: diagnose viral pleurisy or musculoskeletal pain 2

Management Based on Diagnosis

If Benign Cause Confirmed (Viral Pleurisy or Musculoskeletal)

• NSAIDs are appropriate for pain management in those with virally triggered or nonspecific pleuritic chest pain 2
• Regular acetaminophen as primary analgesic, with NSAIDs as second-line for severe pain 5
• Reassure that condition is benign and self-limited 5
• Avoid movements or postures that worsen pain 5

Critical Pitfalls to Avoid

• Do not dismiss pulmonary causes in young vapers—vaping-associated lung injury can present with pleuritic chest pain and respiratory distress 3
• Do not attribute symptoms to musculoskeletal causes without first obtaining chest X-ray to exclude pneumothorax and pneumonia 1, 4, 2
• In patients with persistent symptoms or those who vape, document radiographic resolution with repeat chest X-ray 6 weeks after initial presentation 2
• Pain with inspiration does not exclude serious pathology—PE, pneumothorax, and pneumonia all present with pleuritic pain 1, 3, 2