What is the initial treatment plan for an adult patient with no significant medical history presenting with pleurisy?

Initial Treatment Plan for Pleurisy

For an adult with no significant medical history presenting with pleurisy, begin with NSAIDs for pain control while simultaneously ruling out life-threatening causes (pulmonary embolism, myocardial infarction, pericarditis, pneumothorax, pneumonia), then treat the underlying etiology once identified. 1, 2

Immediate Assessment and Risk Stratification

Rule Out Life-Threatening Causes First

• Pulmonary embolism is the most common serious cause, occurring in 5-21% of patients presenting with pleuritic chest pain 2, 3
• Evaluate for myocardial infarction, pericarditis, pneumothorax, and pneumonia before diagnosing simple pleurisy 1, 2
• Obtain vital signs to assess for fever (suggesting infection) or tachycardia (suggesting PE or infection) 1
• Perform chest radiography in all patients with pleuritic pain 2, 3
• Order electrocardiography if clinical suspicion exists for MI, PE, or pericarditis 2, 3

Physical Examination Findings

• Listen for pleural friction rub, assess for decreased breath sounds, and check for dullness to percussion 1
• These findings indicate pleurisy or effusion and guide further workup 1

Imaging and Diagnostic Workup

Confirm Pleural Effusion if Present

• Ultrasound is the gold standard for detecting and characterizing pleural fluid, with 92% sensitivity and 93% specificity 4
• Ultrasound is superior to CT for identifying septations, loculations, and fibrin strands 4
• Small effusions (<10mm rim) can be treated with antibiotics alone without drainage 4, 1

Pleural Fluid Analysis When Indicated

• If effusion is present and infection suspected, obtain pleural fluid before starting antibiotics 5
• Send fluid for Gram stain, bacterial culture, and differential cell count 4, 5
• Measure protein and LDH to differentiate transudate from exudate 6
• Check pleural fluid pH if infection suspected: pH <7.2 indicates need for drainage 7

Treatment Based on Etiology

Viral Pleurisy (Most Common Cause)

• Most viral pleuritic effusions are self-resolving and do not require drainage 5
• Common viral pathogens include Coxsackieviruses, RSV, influenza, parainfluenza, mumps, adenovirus, CMV, and EBV 3
• Treat with NSAIDs for pain management 2, 3
• No specific antiviral therapy is typically needed 2

Bacterial Pleurisy/Parapneumonic Effusion

• All patients with suspected pleural infection require hospital admission 5
• Start immediate IV antibiotics before culture results 5
• First-line regimen: cefuroxime 1.5g IV three times daily + metronidazole 400mg three times daily 4, 5
• Alternative: benzyl penicillin 1.2g IV four times daily + ciprofloxacin 400mg IV twice daily 4
• Beta-lactams are preferred due to excellent pleural space penetration 4, 5
• Avoid aminoglycosides entirely—they have poor pleural penetration and become inactive in acidic pleural fluid 4, 5

Drainage Indications

• Frank pus, positive Gram stain, or pH <7.2 mandate drainage 5
• Effusions >40% of hemithorax require drainage 5
• Use small-bore chest tube (14F or smaller) for initial drainage 7
• Ultrasound guidance reduces complications and optimizes tube placement 4, 5

Advanced Therapies for Complicated Effusions

• If chest tube drainage ceases with residual pleural collection after 48-72 hours, consider combination TPA (10mg twice daily) + DNase (5mg twice daily) for 3 days 7, 1, 5
• Obtain patient consent due to bleeding risk 7
• Do not use streptokinase—it increases complications without improving outcomes 7
• Single-agent TPA or DNase should not be used 7

Monitoring and Follow-Up

Reassessment Timeline

• Reassess all patients at 48-72 hours regardless of initial effusion size 4, 1
• Signs requiring escalation to drainage include: persistent fever despite antibiotics, enlarging effusion, clinical deterioration, or respiratory compromise 4, 1

Antibiotic Duration

• Continue IV antibiotics until clinical improvement: resolution of fever, improved respiratory status, decreasing WBC 4
• Total duration is typically 2-4 weeks depending on response and drainage adequacy 4
• Switch to oral amoxicillin-clavulanate 1g/125mg three times daily when criteria for oral therapy are met 4, 1

Specialist Involvement

• Involve a respiratory physician or thoracic surgeon early in all patients requiring chest tube drainage 4, 5
• Specialist involvement reduces mortality and improves outcomes 4
• Consider surgical consultation after 7 days if no improvement with drainage and antibiotics 4, 5

Critical Pitfalls to Avoid

• Do not delay antibiotics while awaiting culture results in suspected infection 5
• Do not routinely drain small effusions (<10mm)—they typically resolve with antibiotics alone 4, 5
• Do not use aminoglycosides for pleural infections—they are ineffective and potentially nephrotoxic 4, 5
• Do not use streptokinase for fibrinolytic therapy—it increases complications 7
• Do not contaminate pleural fluid pH samples with local anesthetic or heparin, as this falsely lowers pH 7
• Do not consider early VATS or thoracotomy over chest tube drainage for initial treatment 7