Pleurisy

Pain in the chest often aggravated during deep breath or cough is main symptom of pleurisy. Pain may be located in the shoulder in few cases. Other symptoms like fever, cough, breathlessness and hemoptysis may be present depending on underlying etiology.

Pleural effusion may follow pleurisy characterized by collection of fluid in pleural cavity which can cause coughing and breathlessness [5]. On examination, restriction to rib movements and pleural rub may be present. Pleural rub may be heard on deep inspiration or around pericardium.

A preliminary physical examination to determine restriction to chest movements, pleural rub, breath sounds, rales, and egophony, third heart sound (S3), blood pressure, pulse rate and temperature should be quickly carried out. Chest X-ray along with a complete blood count (CBC) is recommended for all patients with pleuritic chest pain, but normal radiograph does not exclude a pulmonary cause of pleurisy [6].

Further pleurisy often is associated with a pleural effusion identified on a chest radiograph leading to pleural fluid examination. ECG evaluation and/or CT scan of chest is recommended in a case of clinical suspicion of myocardial infarction, pulmonary embolism, or pericarditis. Other diagnostic test could be performed based on expected etiology like connective tissue disorder or drug induced pleurisy.

Primary cause of pleurisy as well the pleuritic chest pain must be treated simultaneously. Pleuritic chest pain could be controlled initially by nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs do not suppress respiratory efforts or cough reflex and are the preferred first-line agent. Narcotic analgesics may be required to relieve severe pleuritic chest pain [7]. Indomethacin (50 to 100 mg orally with food three times per day) has been found to be effective in relieving pleural pain. NSAIDs are first-line therapy for patients with postcardiac injury syndrome. Corticosteroids are reserved for those who are intolerant or experience no response to NSAIDs. Oral corticosteroids are recommended for patients with lupus pleuritis.

Primary cause of pleurisy could be treated based on the underlying condition like causal agent should be discontinued in drug-induced pleuritis, smoking cessation in a case of pleurisy caused by asbestosis and rational chemotherapy based on the suspected underlying organism. In cases of pleuritis with refractory pleural effusions resulting from malignancy or chronic renal failure decortications could be considered. Colchicine is used (1.2 to 2.0 mg orally once per day, or twice per day in divided doses) for treating familial mediterranean fever [8].

Prognosis of pleurisy depends on underlying cause i.e. pulmonary infarction, tuberculosis or bronchial carcinoma which is dependent on response to treatment, recurrence of underlying cause, compliance to treatment.

Viral infection is a commonest cause of pleurisy. In 5 to 20 percent of patients who present to the emergency department with pleuritic pain, pulmonary embolism is the most common potentially life-threatening cause. Whereas, in other cases underlying cause could be bronchial carcinoma, pericarditis, pneumonia, myocardial infarction, pulmonary tuberculosis and pneumothorax [2].

Once a common disease, pleurisy is now quite infrequent due to the development of antibiotics. Pleurisy represents 15.9% of hospitalizations in pneumology department and is more prevalent in men aged of 41 years 55. 60% of cases are associated with serofibrinous exudate, purulent in 25% of cases and hemorrhagic in 15%. 60% of hemorrhagic pleurisy is due to cancer. A serology test for HIV is positive in 56% of cases. Coinfection with HIV is the principal cause of morbidity and mortality [3].

Pleurisy is inflammation of the parietal pleura and depending on the character of exudate it could be serous, fibrinous, serofibrinous, suppurative or hemorrhagic. Parietal pleurae along the ribs and lateral part of each hemidiaphragm are innervated by intercostal nerves. The parietal pleura when inflamed activates somatic pain receptors and somatic nerves that sense pain localized to the cutaneous distribution of those nerves [4]. The phrenic nerve supplies the central part of each hemidiaphragm, when activated, pain is referred to the ipsilateral neck or shoulder.

Prevention of pleurisy depends on prevention underlying cause i.e. pulmonary infarction, tuberculosis, bronchial carcinoma or viral infection. This includes early diagnosis and treatment of deep venous thrombosis, pneumonia, tuberculosis, bronchial carcinoma etc. Smoking cessation and withdrawing drugs which may cause pleurisy may be recommended [9].

Pleurisy is inflammation of the parietal pleura that typically results in characteristic pleuritic pain or pleural rub. It has a variety of possible causes and may be life-threatening to benign. Patients should be evaluated by taking history and performing clinical examination [1]. Chest radiography is recommended for all patients with pleuritic chest pain. Electrocardiography and CT scan of chest are needed if there is clinical suspicion of myocardial infarction, pericarditis or pulmonary embolism. Mainstays of treatment are treatment of underlying cause and relieve pleural pain in order to allow patient to breathe normally or cough efficiently.

Definition

Pleurisy is pain in chest aggravated upon breathing or coughing, as a result of any disease process involving the covering of lungs called pleura.

Cause

Viral infection is a common cause of pleurisy. Other causes include pulmonary embolism, bronchial carcinoma, pericarditis, pneumonia, myocardial infarction, pulmonary tuberculosis and pneumothorax [10].

Symptoms

Pain in the chest often aggravated during deep breath or cough is main symptom of pleurisy. Pain may be located in the shoulder in few cases. Coughing and breathlessness suggests collection of fluid in lung covering.

Diagnosis

A quick preliminary examination including vital signs is followed by chest radiograph and blood test in all cases. Other investigation like ECG and/or CT scan of chest could be suggested depending on suspected underlying cause.

Treatment

Chest pain could be reduced with treatment of nonsteroidal anti-inflammatory drugs (NSAIDs). If pain is severe and not controlled by NSAIDs, narcotic analgesics may be required to relieve severe pleuritic chest pain. Primary cause of pleurisy like pulmonary embolism, bronchial carcinoma, pericarditis, pneumonia, myocardial infarction, pulmonary tuberculosis and pneumothorax must be treated along with control of the pleuritic chest pain.

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