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Pleurisy

Pleurisies

Pleurisy is inflammation of the lining of the lungs which causes chest pain upon breathing or coughing. Pleurisy is a result of any disease process involving the pleura and giving rise to pleuritic pain or pleural friction. It is a common feature of pulmonary infarction and it may be first manifestation of pleural invasion by tuberculosis or bronchial carcinoma.


Presentation

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.

Pleural Effusion
  • The differential diagnostic utilities of the levels of soluble interleukin (IL)-12p40 and the IL-2 receptor in sera and pleural effusions were evaluated in patients with exudative pleural effusions.[ncbi.nlm.nih.gov]
  • Four weeks later although her right sided pleural effusion was subsiding she developed a left sided pleural effusion. Closed pleural biopsy on the left side showed granulomatous inflammation with early caseation.[ncbi.nlm.nih.gov]
  • Medical thoracoscopy is an effective and safe procedure for diagnosing pleural effusions of undetermined causes.[ncbi.nlm.nih.gov]
  • The concentrations of IL-27, IFN-γ and ADA were simultaneously determined in pleural fluids and sera from 40 patients with TPE; 26 with malignant pleural effusion, seven with infectious pleural effusion, and eight with transudative pleural effusion by[ncbi.nlm.nih.gov]
  • The positive rates of AFB smear and M.tb culture in the pleural effusion were 5.8% (2/42) and 10.6% (5/47), respectively.[ncbi.nlm.nih.gov]
Pleuritic Pain
  • Other causes of pleurisy and pleuritic pain There are other more serious causes of pleuritic pain but these are much less common than viral pleurisy.[patient.info]
  • Various other lung disorders can also cause a 'pleuritic pain' similar to pleurisy. A pleuritic pain is a chest pain which is typically sharp and 'stabbing' in a part of the chest. The pain is usually made worse when you breathe in or cough.[patient.info]
  • Causes of serious viral infection may have varying symptoms even apart from pleuritic pain. An X-ray of the chest may help in determining the causes of the viral infection. Blood tests can also be useful.[newsmax.com]
  • C 19 Patients with pleuritic pain should have chest radiography to evaluate for underlying pneumonia. C 9 Nonsteroidal anti-inflammatory drugs should be used to control pleuritic pain.[aafp.org]
Rales
  • Auscultation gives crepitant and sub-crepitant rales, and later bronchial breathing and no friction sound; and, lastly, there will be no displacement of neighboring organs.[henriettes-herb.com]
  • It may also occur in about 4 percent of patients with pneumonia and 4 percent of patients with pulmonary embolism. 28 Additional physical findings on the pulmonary examination may include decreased breath sounds, rales, and egophony, especially in patients[aafp.org]
Chest Wall Tenderness
  • More common causes of chest wall tenderness are myofascial pain and muscle strain. It is an inflammation of the outer layer of pleura (parietal pleura) that causes pain [1] .[ehealthstar.com]
Malaise
  • Symptoms Common symptoms are those associated with respiratory illness such as cough, fever and malaise. Localized chest pain may occur in the form of pain with each breath and pain worsened by coughing or deep breathing.[breathebayarea.org]
  • .  Pleural friction rub grating or leathery sounds heard in both phases of respiration; heard low in the axilla or over the lung base posteriorly; may be heard for only a day or so  Evidence of infection; fever, malaise, increased white cell count 6[slideshare.net]
  • ., days to weeks) Malignancy Rheumatoid arthritis Tuberculosis Recurrent Familial Mediterranean fever Features that are associated with life-threatening causes of pleuritic pain are listed in Table 3 . 3 – 5 , 8 , 9 , 21 , 22 Other symptoms, such as malaise[aafp.org]
Chest Pain
  • This is the first report of MAC-SPN occurring with persistent chest pain, suggesting that MAC should be considered in the differential diagnosis of a solitary pulmonary nodule, even for patients who experience persistent chest pain.[ncbi.nlm.nih.gov]
  • A 28-year-old rheumatoid arthritis woman treated with adalimumab was admitted with fever, cough, and right chest pain. X-ray showed right pleural effusion.[ncbi.nlm.nih.gov]
  • Some of your blood may be sent to the lab for analysis to help rule out other causes of chest pain. Can Pleurisy Symptoms Be Treated at Home? Some chest pain is dangerous.[emedicinehealth.com]
Skin Patch
  • The results of the laboratory studies suggested an immunopathogenetic mechanism, but in vitro lymphocyte-proliferation studies and skin patch tests with bromocriptine were negative. Bromocriptine should be considered as a cause of pleurisy.[ncbi.nlm.nih.gov]
Shoulder Pain
  • Some people also experience shoulder pain. Other symptoms accompanying pleurisy include: Bluish discoloration of the skin Coughing Rapid breathing Shortness of breath How Is Pleurisy Treated? The treatment for pleurisy depends on the cause.[newhealthadvisor.com]
  • Here are additional symptoms: Problems in breathing Muscle aches Joint pain Headaches Pain in your back and shoulders Pain on one side of your chest Pleurisy can be accompanied with fluid buildup (pleural effusion) that pressurizes your lungs thus preventing[newhealthguide.org]
  • This pain can effect the chest cavity in either the front or back of the cavity, and sometimes patient's have back or shoulder pain .[medicinenet.com]
  • pain palpitations n tightened chest) now after been on antibiotics 4 nearly week the broken crushing rib hugging pain gone but I have a horrible burning pain all across back under shoulder blades now had it in rite lung does this mean its spread or is[medhelp.org]
Back Pain
  • Most other causes of back pain don't have this quality, however, for some people back pain will worsen with cough . (As can be seen in spinal disc disease.) Source: Getty Images How is pleurisy diagnosed? The pain of pleurisy is very distinctive.[medicinenet.com]
Spastic Paraplegia
  • A 70-year-old male developed eosinophilic pleurisy fifteen years after dantrolene sodium had been started for his spastic paraplegia due to spinocerebellar degeneration. Drug lymphocyte stimulation test (DLST) for dantrolene was positive.[ncbi.nlm.nih.gov]

Workup

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.

Pleural Effusion on Chest X-Ray
  • Risk of residual pleural effusion on chest X-ray was reduced by 45% at eight weeks (RR 0.54, 95% CI 0.37 to 0.78; 237 participants, 2 trials, low certainty evidence), and 65% at 24 weeks (RR 0.35, 95% CI 0.18 to 0.66; 237 participants, 2 trials, low certainty[ncbi.nlm.nih.gov]
Mycobacterium Fortuitum
  • A case of tuberculous pleurisy due to Mycobacterium fortuitum in a 47-year-old woman with chronic granulocytic leukemia is described.[ncbi.nlm.nih.gov]
Rickettsia Conorii
  • Rickettsia conorii is endemic in Mediterranean area. We describe an unusual sace of R. Conorii infection, which concerns a farmer with clinical, radiological and cytological findings of pleurisy without evidence of malignancy.[ncbi.nlm.nih.gov]
Pleural Effusion
  • The differential diagnostic utilities of the levels of soluble interleukin (IL)-12p40 and the IL-2 receptor in sera and pleural effusions were evaluated in patients with exudative pleural effusions.[ncbi.nlm.nih.gov]
  • Four weeks later although her right sided pleural effusion was subsiding she developed a left sided pleural effusion. Closed pleural biopsy on the left side showed granulomatous inflammation with early caseation.[ncbi.nlm.nih.gov]
  • Medical thoracoscopy is an effective and safe procedure for diagnosing pleural effusions of undetermined causes.[ncbi.nlm.nih.gov]
  • The concentrations of IL-27, IFN-γ and ADA were simultaneously determined in pleural fluids and sera from 40 patients with TPE; 26 with malignant pleural effusion, seven with infectious pleural effusion, and eight with transudative pleural effusion by[ncbi.nlm.nih.gov]
  • The positive rates of AFB smear and M.tb culture in the pleural effusion were 5.8% (2/42) and 10.6% (5/47), respectively.[ncbi.nlm.nih.gov]
Pleural Rub
  • On auscultation a loud pleural rub was heard at the left base together with bilateral basal crepitations. The chest radiograph showed hilar enlargement as well as diffuse lung shadowing.[ncbi.nlm.nih.gov]
  • Diagnosis - Based on symptoms and hearing a pleural rub with a stethoscope. - Chest X-ray often reveals the underlying cause of the pleurisy. - Blood tests and sputum analysis may be necessary, particularly if the condition is severe or does not respond[nursingtimes.net]
  • Doctors usually check for a sound caused by pleurisy, often described as a pleural "rub," by listening for the creaky, scratchy sound of the pleura rubbing together during a breath.[chealth.canoe.com]
  • Your doctor may hear what is known as a pleural rub — a squeaky rubbing sound in the chest. This is a classic sign of pleurisy. Tests The following tests may be used to help diagnose the cause of pleurisy.[mydr.com.au]

Treatment

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

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.

Etiology

Viral infection is a commonest cause of pleurisy. In 5 to 20 percent of patients who present to the emergency department with pleuritic painpulmonary 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].

Epidemiology

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].

Sex distribution
Age distribution

Pathophysiology

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

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].

Summary

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.

Patient Information

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.

References

Article

  1. Crum-Cianflone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev. Jul 2008;21(3):473-94.
  2. Aiello M, Chetta A, Marangio E, Zompatori M, Olivieri D. Pleural involvement insystemicdisorders.Curr Drug Targets Inflamm Allergy. 2004;3:441–7.
  3. HullR D, Raskob GE, Carter CJ, Coates G, Gill GJ, Sackett DL, et al. Pulmonaryembolismin outpatients with pleuriticchestpain. Arch Intern Med. 1988;148:838–44.
  4. Tagarakis GI, Georgios TI, Karangelis D, Dimos K, Tsolaki F, Fani T. Bornholm disease--a pediatric clinical entity that can alert a thoracic surgeon. J Paediatr Child Health. Apr 2011;47(4):242. 
  5. Branch WT Jr, McNeil BJ. Analysis of the differential diagnosis and assessment of pleuritic chest pain in young adults. Am J Med. Oct 1983;75(4):671-9.
  6. Perrier A, Roy PM, Aujesky D, Chagnon I, Howarth N, Gourdier AL, et al. Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study. Am J Med. 2004;116:291–9.
  7. Nolte FS. Case studies in cost effectiveness of molecular diagnostics for infectious diseases: pulmonary tuberculosis, enteroviral meningitis, and BK virus nephropathy. Clin Infect Dis. Dec 1 2006;43(11):1463-7.
  8. Conde MB, Loivos AC, Rezende VM, Soares SL, Mello FC, Reingold AL, et al. Yield of sputum induction in the diagnosis of pleural tuberculosis. Am J Respir Crit Care Med. 2003;167:723–5.
  9. McEvoy GK. Nonsteroidal Anti-inflammatory Agents. In: AHFS Drug information. Bethesda, Md: American Society of Health-System Pharmacists; 2000.
  10. Thomas L, Reichl M. Pulmonary embolism in patients attending the accident and emergency department with pleuritic chest pain. Arch Emerg Med. Mar 1991;8(1):48-51. 

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Last updated: 2017-08-09 18:11