Pleuritic Chest Pain: Sorting Through the Differential Diagnosis

 

Am Fam Physician. 2017 Sep 1;96(5):306-312.

Author disclosure: No relevant financial affiliations.

Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. Pulmonary embolism is the most common serious cause, found in 5% to 21% of patients who present to an emergency department with pleuritic chest pain. A validated clinical decision rule for pulmonary embolism should be employed to guide the use of additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography. Myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax are other serious causes that should be ruled out using history and physical examination, electrocardiography, troponin assays, and chest radiography before another diagnosis is made. Validated clinical decision rules are available to help exclude coronary artery disease. Viruses are common causative agents of pleuritic chest pain. Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus are likely pathogens. Treatment is guided by the underlying diagnosis. Nonsteroidal anti-inflammatory drugs are appropriate for pain management in those with virally triggered or nonspecific pleuritic chest pain. In patients with persistent symptoms, persons who smoke, and those older than 50 years with pneumonia, it is important to document radiographic resolution with repeat chest radiography six weeks after initial treatment.

Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. It is exacerbated by deep breathing, coughing, sneezing, or laughing. When pleuritic inflammation occurs near the diaphragm, pain can be referred to the neck or shoulder. Pleuritic chest pain is caused by inflammation of the parietal pleura and can be triggered by a variety of causes.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A thorough history and physical examination should be performed to diagnose or exclude life-threatening causes of pleuritic chest pain.

C

18

Pulmonary embolism is the most common life-threatening cause of pleuritic chest pain and should be considered in all patients with this symptom. A validated clinical decision rule should be applied to guide the use of additional tests such as d-dimer assays and imaging studies.

C

11, 12, 3033

Patients with unexplained pleuritic chest pain should have chest radiography to evaluate for abnormalities, including pneumonia, that may be the cause of their pain.

C

1

Nonsteroidal anti-inflammatory drugs should be used to control pleuritic pain.

B

36


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A thorough history and physical examination should be performed to diagnose or exclude life-threatening causes of pleuritic chest pain.

C

18

Pulmonary embolism is the most common life-threatening cause of pleuritic chest pain and should be considered in all patients with this symptom. A validated clinical decision rule should be applied to guide the use of additional tests such as d-dimer assays and imaging studies.

C

11, 12, 3033

Patients with unexplained pleuritic chest pain should have chest radiography to evaluate for abnormalities, including pneumonia, that may be the cause of their pain.

C

1

Nonsteroidal anti-inflammatory drugs should be used to control pleuritic pain.

B

36


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Pathophysiology

The visceral pleura does not contain pain receptors, whereas the parietal pleura is innervated by somatic nerves that sense pain due to trauma or inflammation. Inflammatory mediators released into the pleural space trigger local pain receptors. Parietal pleurae at the periphery of the rib cage and lateral hemidiaphragm are innervated by intercostal nerves. Trauma or inflammation in these regions results in pain localized in the cutaneous distribution of those nerves. In contrast, the phrenic nerve innervates the central diaphragm and can refer pain to the ipsilateral neck or shoulder.

Differential Diagnosis

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The Authors

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BRIAN V. REAMY, MD, is a professor of family medicine and the Senior Associate Dean for Academic Affairs at the Uniformed Services University of the Health Sciences, Bethesda, Md....

PAMELA M. WILLIAMS, MD, is an associate professor of family medicine at the Uniformed Services University of the Health Sciences, and the Director of Medical Education at the Mike O'Callaghan Federal Medical Center, Las Vegas, Nev.

MICHAEL RYAN ODOM, MD, is an assistant professor of family medicine at the Uniformed Services University of the Health Sciences, and a faculty member in the Family Medicine Residency at the Mike O'Callaghan Federal Medical Center.

Address correspondence to Brian V. Reamy, MD, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 21037 (e-mail: brian.reamy@usuhs.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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