What are the causes of pleuritic chest pain in a 36-year-old man?

Causes of Pleuritic Chest Pain in a 36-Year-Old Man

In a 36-year-old man with pleuritic chest pain, the most critical causes to exclude immediately are pulmonary embolism (present in 5-21% of emergency presentations), pneumothorax, acute coronary syndrome (which can present with pleuritic features in 13% of cases), pericarditis, and aortic dissection, before considering more benign etiologies such as viral pleurisy or costochondritis. 1, 2, 3, 4

Life-Threatening Causes (Must Rule Out First)

Pulmonary Embolism

• Most common serious cause, accounting for 5-21% of patients presenting to emergency departments with pleuritic chest pain 3, 4
• Presents with dyspnea, pleuritic chest pain, tachycardia (>90% of cases), and tachypnea (approximately 70% of cases) 5, 1, 6
• Pain is caused by pleural irritation from distal emboli causing pulmonary infarction with alveolar hemorrhage 5, 1
• Pleural effusion develops in approximately 46% of PE cases and is frequently hemorrhagic 5, 1
• Key risk factors include: recent immobilization (past 4 weeks), prior DVT/PE, active malignancy, recent surgery, prolonged travel, and age >65 years 1, 6

Pneumothorax

• Classic triad: dyspnea, sharp pleuritic pain on inspiration, and unilateral absent breath sounds with hyperresonant percussion 1, 2, 6
• Primary spontaneous pneumothorax is characterized by acute chest pain and occurs more commonly in tall, thin young men 7, 3

Acute Coronary Syndrome

• Critical pitfall: Approximately 13% of ACS patients present with pleuritic-type chest pain 1, 2, 6
• Sharp, pleuritic pain does NOT exclude myocardial ischemia 1, 2
• Up to 7% of patients with reproducible chest wall tenderness on palpation still have acute coronary syndrome 1, 2, 6

Aortic Dissection

• Sudden "ripping" or "tearing" chest or back pain that is maximal at onset 2, 6
• Pulse or blood pressure differential between extremities occurs in approximately 30% of cases 2, 6

Pericarditis

• Sharp, pleuritic chest pain that improves when sitting forward and worsens when lying supine is pathognomonic 5, 1, 2, 6
• Pericardial friction rub may be audible (though absence does not exclude disease) 5, 1, 2
• ECG shows widespread ST-elevation with PR-segment depression 5, 1, 2

Common Pulmonary Causes

Pneumonia

• Presents with localized pleuritic pain, fever, productive cough, and crackles on auscultation 1, 2, 3
• Pain associated with respiratory infection rarely poses a difficult diagnostic problem 7
• Regional dullness to percussion, egophony, and possible pleural friction rub may be present 2

Viral Pleurisy

• Most common benign cause after life-threatening conditions are excluded 3, 4
• Common viral pathogens include Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus 3
• Often follows a viral prodrome 2

Pleural Effusion

• May cause ongoing pleuritic discomfort 1, 2
• Dyspnea is the most common presenting symptom along with pleuritic chest pain 1

Musculoskeletal Causes

Costochondritis

• Most common cause (42%) of nontraumatic musculoskeletal chest wall pain 5
• Characterized by tenderness of costochondral joints on palpation, reproducible with direct pressure 1, 2, 6
• Accounts for approximately 43% of chest pain presentations in primary care settings 6
• Important caveat: 7% of patients with reproducible chest wall tenderness still have acute coronary syndrome 1, 2, 6

Other Important Causes

Malignancy

• Lung cancer and mesothelioma typically present with constant pain unrelated to respiratory movements (distinguishing feature from pleuritic pain) 1, 7
• Pleural extension of pulmonary malignancy may mimic benign pleuritic pain 1

Asbestos-Related Pleural Disease

• Can cause acute pleural effusion with fever and severe pleuritic pain 1, 2
• Occupational exposure history is key 1

Immediate Diagnostic Algorithm (First 10 Minutes)

Essential Initial Testing

• Obtain 12-lead ECG within 10 minutes to identify STEMI, pericarditis patterns (diffuse ST-elevation with PR-depression), or PE-related changes 1, 2, 6
• Measure cardiac troponin immediately as the most sensitive biomarker for myocardial injury 1, 2, 6
• Obtain PA and lateral chest radiograph to screen for pneumothorax, pneumonia, pleural effusion, or mediastinal widening 1, 2, 6
• Assess vital signs: tachycardia and tachypnea are present in >90% of PE cases; pulse/BP differentials suggest aortic dissection 2, 6

Risk Stratification for Pulmonary Embolism

• Apply Wells criteria or revised Geneva score to estimate pre-test probability 5, 1, 2, 6
• In low-to-intermediate probability patients, obtain age- and sex-adjusted D-dimer; a negative result effectively rules out PE 1, 2, 6
• If probability is high or D-dimer is positive, proceed directly to CT pulmonary angiography (CTPA) 1, 2, 6

Critical Pitfalls to Avoid

• Never assume reproducible chest wall tenderness excludes serious pathology: 7% of patients with palpable tenderness have acute coronary syndrome 1, 2, 6
• Do not use nitroglycerin response as a diagnostic criterion: relief with nitroglycerin does not confirm or exclude myocardial ischemia 1, 2
• Sharp, pleuritic pain does not exclude cardiac ischemia: 13% of ACS patients present with pleuritic-type pain 1, 2, 6
• A normal chest X-ray does not exclude pulmonary embolism or other serious conditions 1, 2, 6
• A completely normal physical examination does not rule out myocardial infarction 1, 6

Disposition Based on Clinical Findings

• If high suspicion for PE, pneumothorax, ACS, or aortic dissection exists: activate emergency medical services for immediate transport; do not delay for additional office testing 2, 6
• If cardiac testing (ECG and troponin) is normal and pain is reproducible with palpation: diagnose costochondritis and treat with NSAIDs (ibuprofen 600-800 mg TID for 1-2 weeks) 6, 3, 4
• If pericarditis is confirmed: initiate high-dose aspirin (500 mg-1 g every 6-8 hours) plus colchicine (0.5-0.6 mg once or twice daily for approximately 3 months) and arrange cardiology consultation 2, 6