What are the differential diagnoses and initial work‑up for pleuritic chest pain without cough?

Pleuritic Chest Pain Without Cough: Differential Diagnosis and Initial Work-Up

In a patient presenting with pleuritic chest pain but no cough, you must immediately rule out pulmonary embolism, acute coronary syndrome, pneumothorax, pericarditis, and aortic dissection before considering benign causes—these life-threatening conditions can present without cough and require urgent intervention. 1

Immediate Assessment (First 10 Minutes)

Obtain a 12-lead ECG within 10 minutes of presentation to identify STEMI, pericarditis patterns (diffuse ST elevation with PR depression), or signs suggestive of PE. 1, 2

Measure cardiac troponin immediately to exclude myocardial injury, as 13% of patients with pleuritic pain have acute myocardial ischemia. 3, 2

Order PA and lateral chest radiograph to evaluate for pneumothorax (unilateral absent breath sounds with hyperresonance), pleural effusion, or widened mediastinum suggesting aortic dissection. 1, 2

Assess vital signs carefully: tachycardia and tachypnea occur in >90% of pulmonary embolism cases, even without cough. 1, 2

Life-Threatening Causes to Exclude First

Pulmonary Embolism

• Most common serious cause, found in 5-21% of patients presenting with pleuritic pain. 4, 5
• Dyspnea and pleuritic pain are the dominant symptoms; tachycardia and tachypnea present in >90% of cases. 1, 3
• Apply validated clinical decision rules (Wells criteria) to determine pretest probability. 3, 2
• For low-to-intermediate probability, use age- and sex-specific D-dimer cutoffs; negative D-dimer effectively rules out PE. 3, 2
• For high clinical suspicion or positive D-dimer, proceed directly to CT pulmonary angiography. 3, 2
• Pleural effusion develops in 46% of PE cases and is frequently hemorrhagic. 3, 6

Acute Coronary Syndrome

• Critical pitfall: 13% of patients with pleuritic pain have acute myocardial ischemia, and sharp pleuritic features do NOT exclude cardiac ischemia. 3, 2
• Atypical presentations are more common in elderly, women, diabetics, and those with renal insufficiency. 3
• 7% of patients with reproducible chest wall tenderness still have ACS—never assume palpable tenderness excludes serious pathology. 3, 2
• Central PE can present with retrosternal angina-like pain reflecting right ventricular ischemia. 3, 6

Pneumothorax

• Classic triad: dyspnea, pleuritic pain on inspiration, and unilateral absence of breath sounds with hyperresonant percussion. 1, 2
• May occur without preceding cough, especially in primary spontaneous pneumothorax. 7

Aortic Dissection

• Sudden onset "ripping" chest or back pain with pulse differential in 30% of cases. 1, 2
• Look for connective tissue disorders (Marfan syndrome) and widened mediastinum on chest X-ray. 1

Pericarditis

• Pathognomonic feature: sharp pleuritic pain that improves sitting forward and worsens supine. 1, 2, 6
• This positional quality effectively excludes pulmonary embolism. 2
• May present with pericardial friction rub (biphasic, coarse, grating sound during inspiration and expiration, not cleared by coughing). 3, 6
• ECG shows diffuse concave ST elevation with PR depression. 1, 2
• Recent viral prodrome combined with positional chest pain strongly supports viral pericarditis, even with normal initial ECG. 2

Other Important Causes Without Cough

Pneumonia

• Can present with localized pleuritic pain and pleural friction rub even without prominent cough initially. 1
• Look for fever, regional dullness to percussion, and egophony. 1, 2
• Elderly patients may lack typical symptoms despite having pneumonia on imaging. 6

Musculoskeletal (Costochondritis/Tietze Syndrome)

• Tenderness of costochondral joints on palpation confirms the diagnosis. 1, 2
• However, remember that 7% with reproducible tenderness have ACS—do not rely on this finding alone to exclude cardiac disease. 3, 2

Pleural Effusion

• Dyspnea is the most common symptom along with pleuritic chest pain. 6
• In malignant effusions (mesothelioma), pain is typically dull and constant rather than pleuritic. 6

Critical Pitfalls to Avoid

Never use nitroglycerin response as a diagnostic criterion—relief with nitroglycerin does not confirm or exclude myocardial ischemia or pericarditis. 3, 2

Do not delay transfer for troponin testing in office settings—patients with suspected ACS should be transported urgently to the ED by EMS. 3, 2

Sharp, pleuritic pain does NOT exclude cardiac ischemia—maintain high suspicion for ACS even with classic pleuritic features. 3, 2

A normal chest X-ray does NOT exclude PE or other serious conditions—proceed with appropriate risk stratification and further testing. 2

Diagnostic Algorithm

1. Within 10 minutes: ECG, troponin, chest X-ray, vital signs 1, 2

2. If positional pain (worse supine, better sitting forward): Consider pericarditis; obtain TTE to evaluate for effusion 1, 2

3. If risk factors for PE or unexplained tachycardia/dyspnea: Apply Wells criteria, obtain D-dimer (if low-intermediate probability) or proceed directly to CTPA (if high probability) 3, 2

4. If chest wall tenderness: Do NOT assume benign—still complete cardiac workup given 7% ACS rate 3, 2

5. If sudden onset with pulse differential: Urgent evaluation for aortic dissection with CT angiography 1

6. If unilateral absent breath sounds: Immediate evaluation for pneumothorax 1, 2

7. Only after excluding life-threatening causes: Consider viral pleurisy, musculoskeletal pain, or other benign etiologies 4, 5

Disposition

Activate EMS for immediate ED transport if any concern exists for ACS, PE, pneumothorax, or aortic dissection. 2

Unless a clearly benign noncardiac cause is evident, an ECG should be performed; if unavailable in the office setting, refer the patient to the ED. 1