Diagnostic Approach to Severe Chronic Pleurisy Pain
The diagnosis of chronic pleuritic pain is reached by excluding malignancies and other serious causes, as most acute pleuritis does not result in chronic pain; malignancy is unlikely when pain persists for years with little or no clinical or radiographic change. 1
Understanding Chronic Pleuritic Pain
Chronic severe pleuritic pain is rare in patients with pleural disease. 1 When it does occur, it is typically:
- Present for many years 1
- Disabling in nature 1
- Often bilateral 1
- Associated with radiographic evidence ranging from plaques to extensive diffuse and circumscribed pleural thickening 1
Diagnostic Strategy: Exclusion-Based Approach
Initial Essential Testing
Chest radiography (PA and lateral) is the foundational test for evaluating chronic pleuritic pain, as it can reveal:
- Diffuse pleural thickening 1
- Pleural plaques 1
- Blunted costophrenic angles 1
- Circumscribed pleural thickening 1
Critical Conditions to Exclude
The diagnostic process centers on ruling out serious pathology rather than confirming a specific benign diagnosis:
1. Malignancy (Primary Priority)
- CT chest with contrast is the key diagnostic test when malignancy must be excluded, as it provides superior visualization of pleural abnormalities compared to plain radiography 1
- Pleural fluid cytology is useful for distinguishing benign from malignant effusions if fluid is present 1
- Thoracoscopy with pleural biopsy may be necessary for definitive tissue diagnosis when imaging is inconclusive 1, 2
- Nonspecific effusions can precede mesothelioma by several years; if malignancy has not manifested within 3 years, the effusion is generally considered benign 1
2. Pulmonary Embolism
- CT pulmonary angiography (CTPA) using a PE protocol is the diagnostic test of choice in stable patients with suspected PE 1
- Clinical pretest probability assessment should guide testing decisions 1
- D-dimer testing may be useful in low to intermediate pretest probability patients 1
3. Infectious Causes
- Tuberculosis and other mycobacterial infections must be considered, particularly in chronic cases 2
- Pleural fluid analysis with bacterial and mycobacterial culture is essential when effusion is present 3
Specific Diagnostic Tests for Chronic Pleuritic Pain
When Pleural Effusion is Present:
Thoracentesis with pleural fluid analysis should include: 3
- Protein and LDH levels (to differentiate transudate from exudate) 3
- Cellular differential count 3
- Bacterial and mycobacterial cultures 3
- Cytology 1
When Pleural Thickening Without Effusion:
CT chest (with or without contrast) provides: 1
- Detailed characterization of pleural abnormalities
- Assessment for underlying parenchymal disease
- Evaluation for masses or nodules
When Diagnosis Remains Uncertain:
Surgical pleural biopsy (via VATS or thoracoscopy) is indicated when: 1, 2
- Needle biopsy is non-diagnostic
- Malignancy cannot be excluded by less invasive means
- Chronic symptoms persist without clear etiology
Clinical Context Considerations
Asbestos Exposure History
If there is occupational asbestos exposure: 1
- Chronic pleuritic pain may follow pleural effusions
- Plaques are the most common manifestation (appearing >20 years after first exposure) 1
- Diffuse pleural thickening often underlies chronic pain 1
Key Pitfall to Avoid
Do not assume chronic pleuritic pain is benign without excluding malignancy. The most critical error is failing to adequately rule out mesothelioma or other pleural malignancies, which can present with chronic pain and may not show rapid radiographic progression. 1 Serial imaging over time (typically 3 years) may be necessary to confidently exclude malignancy. 1
Practical Algorithm
- Obtain chest radiograph (PA and lateral) as initial test 1
- Perform CT chest with contrast if radiograph shows pleural abnormalities or clinical suspicion remains high 1
- If pleural effusion present: thoracentesis with comprehensive fluid analysis 1, 3
- If diagnosis uncertain after imaging and fluid analysis: proceed to thoracoscopy with pleural biopsy 1, 2
- If all testing negative: consider diagnosis of chronic pleurisy by exclusion, with serial imaging follow-up over 3 years to ensure no malignancy develops 1