What is the diagnosis and treatment for a male in his 20s with pleuritic chest pain (pain on inspiration)?

Pleuritic Chest Pain in a Male in His 20s

Immediate Action Required

In a male in his 20s with pleuritic chest pain, immediately obtain an ECG within 10 minutes and chest radiography to exclude life-threatening causes—specifically pulmonary embolism, pneumothorax, pericarditis, and acute coronary syndrome—before considering benign diagnoses. 1, 2

Life-Threatening Causes to Exclude First

Pulmonary Embolism

• Most common life-threatening cause, occurring in 5-20% of patients presenting with pleuritic pain 3
• Look for tachycardia and dyspnea (present in >90% of cases), tachypnea, and hypoxemia 1
• Use Wells score or Geneva score to determine pretest probability 2, 4
• If low-to-intermediate probability: obtain D-dimer with age-adjusted cutoffs 2, 4
• If D-dimer elevated or high clinical probability: proceed directly to CT pulmonary angiography 2, 4

Pneumothorax

• Classic triad: dyspnea, pleuritic pain on inspiration, and unilateral absence of breath sounds with hyperresonant percussion 1, 2
• Chest X-ray is diagnostic 2
• More common in young males, especially tall, thin individuals and smokers 3

Pericarditis

• Sharp, pleuritic pain that improves sitting forward and worsens when supine 1, 2
• May have fever and pericardial friction rub on examination 1
• ECG shows widespread ST-elevation with PR depression 2
• Obtain troponin to assess for myopericarditis 2

Acute Coronary Syndrome

• 13% of ACS patients present with pleuritic pain 2
• Measure cardiac troponin immediately, even though pleuritic quality makes ischemia less likely 1, 4
• Repeat troponin at 1-3 hours if initial is negative but suspicion remains 1, 4
• Critical pitfall: Pain with inspiration markedly reduces but does not eliminate ACS probability 1

Common Non-Life-Threatening Causes

Viral Pleurisy

• Most common benign cause after excluding dangerous etiologies 3
• Diagnosis of exclusion after negative workup 5, 3
• May be initial presentation of viral infections including COVID-19 5

Pneumonia

• Fever, productive cough, localized pleuritic pain 1, 2
• Regional dullness to percussion, egophony, possible friction rub 1, 2
• Chest X-ray shows infiltrate 2

Costochondritis/Tietze Syndrome

• Tenderness of costochondral joints on palpation 1, 2
• Critical pitfall: 7% of patients with reproducible chest wall tenderness still have ACS—do not assume benign based on palpation alone 2

Diagnostic Algorithm

Step 1: Immediate Assessment (Within 10 Minutes)

• Obtain vital signs: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation 4
• Perform 12-lead ECG to identify STEMI, pericarditis, or right heart strain 1, 4
• Draw cardiac troponin immediately 1, 4

Step 2: Chest Radiography

• Evaluate for pneumothorax, pneumonia, pleural effusion 2, 4
• Note: Negative chest X-ray does not exclude all pathology (sensitivity only 2-60% for certain conditions) 2

Step 3: Risk Stratification for Pulmonary Embolism

• Calculate Wells score or Geneva score 2, 4, 6
• If low-to-intermediate probability: obtain D-dimer 2, 4
• If high probability or positive D-dimer: CT pulmonary angiography 2, 4

Step 4: Serial Testing if Initial Workup Negative

• Repeat troponin at 3-6 hours if symptoms persist 4
• Serial ECGs if initial nondiagnostic but clinical suspicion remains 4

Treatment Based on Diagnosis

If Pulmonary Embolism Confirmed

• Immediate anticoagulation 1, 2

If Pneumothorax Confirmed

• Small (<15%): observation with supplemental oxygen 2
• Large or symptomatic: chest tube placement 2

If Pericarditis Confirmed

• Anti-inflammatory medications (NSAIDs) 2, 3
• Cardiology consultation 2

If Viral Pleurisy (Diagnosis of Exclusion)

• Pain management with NSAIDs 3
• Supportive care 5, 3

If Costochondritis

• Anti-inflammatory medications 2
• Reassurance after excluding cardiac and pulmonary causes 2

Critical Pitfalls to Avoid

• Never assume reproducible chest wall tenderness excludes serious pathology—7% still have ACS 2
• Do not use nitroglycerin response as diagnostic criterion—relief does not confirm or exclude ischemia 2
• Do not delay transfer for troponin testing in office settings—transport suspected ACS patients urgently to ED by EMS 1, 2
• Sharp, pleuritic pain does not exclude cardiac ischemia—it makes it less likely but not impossible 2
• Young age does not eliminate risk—PE, pneumothorax, and even ACS can occur in males in their 20s 1, 3