What is the appropriate treatment plan for a patient presenting with pleuritis?

Pleuritis Management

Subjective (History)

For pleuritic chest pain, immediately assess for life-threatening causes before diagnosing simple pleurisy. 1, 2

Critical Red Flags to Elicit

• Pulmonary embolism risk factors (found in 5-21% of pleuritic pain presentations): recent immobilization, surgery, malignancy, prior VTE 1, 2
• Cardiac symptoms: radiation to arm/jaw, diaphoresis, nausea suggesting MI or pericarditis 1, 2
• Infectious symptoms: fever, productive cough, night sweats indicating pneumonia, tuberculosis, or empyema 3, 4
• Trauma history: suggesting pneumothorax 1, 2
• Autoimmune disease history: particularly SLE or rheumatoid arthritis, which can cause chronic pleuritic pain 5, 6

Pleurisy-Specific Features

• Pain character: sharp, stabbing, or burning that worsens with inspiration, coughing, or movement 1, 2
• Viral prodrome: recent upper respiratory infection suggesting viral pleurisy (most common benign cause) 1, 2
• Duration and progression: acute versus chronic symptoms 5, 6

Objective (Physical Examination)

Essential Examination Components

• Vital signs: fever suggests infectious etiology; tachycardia/hypotension suggests PE or sepsis 3, 4
• Respiratory examination: pleural friction rub (pathognomonic for pleurisy), decreased breath sounds, dullness to percussion suggesting effusion 3
• Cardiac examination: pericardial friction rub, jugular venous distension 1, 2
• Extremity examination: unilateral leg swelling suggesting DVT/PE 2

Assessment (Diagnosis)

The diagnosis of pleurisy can only be made after excluding life-threatening causes: pulmonary embolism, myocardial infarction, pericarditis, pneumothorax, and pneumonia. 1, 2

Mandatory Initial Workup

• Chest radiography for all patients to identify pneumonia, pneumothorax, or pleural effusion 1, 2
• Electrocardiography to exclude MI, PE, or pericarditis 1, 2
• Chest ultrasound if effusion suspected (92% sensitivity, 93% specificity; superior to CT for characterizing septations and loculations) 7

Risk Stratification for Pleural Effusion

If effusion is present, immediately assess for complicated parapneumonic effusion or empyema 3:

• Small effusion (<10mm rim): treat with antibiotics alone, no drainage required 7
• Moderate effusion (>10mm but <50% hemithorax) with respiratory compromise: requires thoracentesis 7
• Large effusion (>40% hemithorax), loculated effusion, or purulent fluid: requires chest tube drainage 3

Diagnostic Thoracentesis Indications

Perform thoracentesis for any effusion >10mm to exclude empyema 3:

• Send pleural fluid for: pH, Gram stain, bacterial culture, cell count with differential, glucose, LDH, protein 3, 7
• pH <7.2 indicates complicated parapneumonic effusion requiring drainage 3
• Avoid contaminating sample with local anesthetic or heparin (falsely lowers pH) 3

Differential Diagnosis Considerations

• Viral pleurisy: most common benign cause (Coxsackie, RSV, influenza, EBV) 1, 2
• Rheumatoid or lupus pleurisy: consider in patients with known autoimmune disease and chronic symptoms 5, 6
• Tuberculous pleurisy: in high-risk populations with chronic symptoms 8

Plan (Treatment)

Pain Management for Uncomplicated Pleurisy

NSAIDs are the treatment of choice for pain control in viral or nonspecific pleurisy 1, 2:

• Ibuprofen 400-600mg every 6-8 hours, or
• Naproxen 500mg twice daily

Antibiotic Therapy for Infectious Pleurisy/Empyema

If pleural infection is suspected or confirmed, start IV antibiotics immediately—delay increases morbidity and mortality 3, 4:

Community-Acquired Infection (First-Line)

• Cefuroxime 1.5g IV three times daily + metronidazole 500mg IV three times daily 3, 4, 7
• Alternative: Benzyl penicillin 1.2g IV four times daily + ciprofloxacin 400mg IV twice daily 3, 4
• Alternative: Meropenem 1g IV three times daily + metronidazole 500mg IV three times daily 3, 4

Hospital-Acquired Infection

• Piperacillin-tazobactam 4.5g IV every 6 hours (preferred) 4
• Alternative: Ceftazidime 2g IV three times daily 3, 4
• Alternative: Meropenem 1g IV three times daily ± metronidazole 3, 4

MRSA Coverage (if risk factors present)

• Add vancomycin 15mg/kg IV every 8-12 hours (target trough 15-20 mg/mL) OR linezolid 600mg IV every 12 hours 4

Critical Antibiotic Principles

• Never use aminoglycosides (gentamicin, tobramycin, amikacin)—they have poor pleural penetration and are inactivated by acidic pleural fluid 3, 4, 7
• Adjust antibiotics based on culture results when available 3, 4
• Beta-lactams are preferred due to excellent pleural space penetration 3, 7

Transition to Oral Antibiotics

Switch to oral therapy only after clinical improvement (fever resolution, improved respiratory status, decreasing WBC) 4, 7:

• Amoxicillin-clavulanate 1g/125mg three times daily (first-line) 4, 7
• Clindamycin 300mg four times daily (for penicillin allergy) 4
• Continue oral antibiotics for 1-4 weeks after discharge; total duration 2-4 weeks depending on response 4, 7

Pleural Drainage Procedures

Small-bore chest tubes (≤14F) are recommended for initial drainage of pleural infection 3:

• Use ultrasound guidance to reduce complications 3, 7
• Involve respiratory physician or thoracic surgeon early for all patients requiring chest tube drainage 3, 7

Intrapleural Fibrinolytic Therapy

If chest tube drainage ceases with residual collection, use combination TPA + DNase 3:

• TPA 10mg + DNase 5mg, both twice daily for 3 days (standard dose) 3
• Alternative lower dose: TPA 5mg + DNase 5mg, both twice daily for 3 days (may be equally effective) 3
• Obtain informed consent due to bleeding risk 3
• Reduce TPA dose in patients on anticoagulation or with bleeding risk 3
• Do NOT use single-agent TPA or DNase alone—ineffective 3
• Do NOT use streptokinase—not recommended 3

Surgical Intervention

Consider VATS over thoracotomy if surgery is required (less pain, shorter hospital stay, fewer complications) 3:

• Surgical consultation if no improvement after 7 days of drainage and antibiotics 3, 7
• Do NOT perform early VATS or thoracoscopy as initial treatment—chest tube drainage is first-line 3

Monitoring and Follow-Up

• Reassess at 48-72 hours regardless of initial effusion size 7
• Signs requiring escalation: persistent fever, enlarging effusion, clinical deterioration, respiratory compromise 7
• Repeat thoracentesis if clinical improvement not evident to ensure CPPE not missed 3
• Resolution confirmed by: pleural fluid neutrophils <250/mm³, sterile cultures 4

Special Considerations

Autoimmune Pleurisy (SLE, Rheumatoid Arthritis)

• Corticosteroids are first-line treatment for lupus or rheumatoid pleurisy 5, 8
• Pleurectomy/decortication may be considered for medically refractory chronic pleuritis causing severe restriction 5

Tuberculous Pleurisy

• Corticosteroids may reduce systemic symptoms as adjunct to antimicrobial therapy 8

Common Pitfalls to Avoid

• Never delay antibiotics while awaiting culture results in suspected pleural infection 4, 7
• Never use aminoglycosides in pleural infections 3, 4, 7
• Never drain small effusions (<10mm) routinely—they resolve with antibiotics alone 7
• Never use oral antibiotics as initial monotherapy for empyema—inadequate and increases mortality 4
• Never omit anaerobic coverage in community-acquired pleural infections 3, 4
• Never use single-agent fibrinolytics—combination TPA + DNase is required 3