Pleuritic pain is the primary symptom of pleurisy but also occurs with several non-pleural-related pathologies, which need to be kept in mind when someone presents in this way.
Clinical presentation
Pleuritic chest pain is often described by patients as being sharp and focused in nature. Characteristically the pain is aggravated by any action involving a vigorous inspiration/expiration, e.g. sneezing, laughing, coughing, deep breathing etc. It is usually unilateral.
Accompanying signs on physical examination are very variable. If the underlying cause is pleurisy, then a pleural rub may be auscultated. This is a scratchy sound, usually best appreciated on the side of the pain, due to the rubbing of the inflamed visceral and parietal pleura against each other.
Pathology
The visceral pleura completely lacks pain sensation. Conversely, the parietal pleura is replete with nociceptors and richly innervated, which are stimulated by any inflammation/injury to the pleura.
Moreover, any inflammatory process of the adjacent soft tissues can spread to the parietal pleura secondarily causing pain, e.g. lung, pericardium, diaphragm, therefore pathologies such as pneumonia can present with pleuritic pain, despite the absence of a true pleurisy.
Etiology
The possible causes of pleuritic pain are many. This list includes causes of pleurisy, and also other non-pleural pathologies that can stimulate the pain fibers of the parietal pleura.
Pleurisy
- infectious
- viruses: many, e.g. adenovirus, coxsackie, cytomegalovirus, Epstein-Barr virus, influenza, mumps, COVID-19, SARS, MERS
- bacteria: tuberculosis, parapneumonic pleuritis
- parasites: amoebiasis
- exogenous agents
- asbestos
- drugs 1
- amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, methysergide, minoxidil, mitomycin, oxyprenolol, practolol, procarbazine
- medication-induced pleurisy is a distinct phenomenon from the interstitial lung diseases caused by most of these agents
- inflammatory: rheumatoid arthritis, lupus pleuritis, Sjogren syndrome
- cardiac: Dressler syndrome
- gastrointestinal: inflammatory bowel disease, spontaneous bacterial pleuritis
- familial Mediterranean fever
- renal: chronic renal failure
Non-pleural pathology
- pulmonary embolism: most important diagnosis to exclude
- myocardial infarction: pleuritic pain atypical but certainly well-recognized
- pneumothorax
- pericarditis
- pneumonia
- trauma
- Bornholm disease
- pericardial fat necrosis
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