Diagnosis

Pleuritis

Etiology

Cause [g1w][wd1]

1. Viral infection:

   • Coxsackievirus

   • RSV

   • CMV

   • Adenovirus

   • EBV

   • Parainfluenza

   • Influenza

   • Herpes zoster

   • Mumps

2. Bacterial infections:

   • Empyema

   • Tuberculosis

   • Legionellae

   • Bacterial pneumonia

   • Spontaneous bacterial pleuritis

   • Mediterranean spotted fever

3. Fungal/parasitic pneumonia (amebiasis and paragonimiasis), Tuberculosis

4. Autoimmun conditions:

   • Systemic lupus erythematosus

   • Rheumatoid arthritis

   • Crohns Disease/Ulcerative colitis

   • Sarcoidosis

   • Ankylosing spondylitis

   • Sjögren syndrome

   • Familial Mediterranean fever

5. Pulmonary Conditions:

   • Chronic obstructive pulmonary disease

   • Hemothorax

   • Pneumothorax

   • Pulmonary adhesions

   • Pulmonary embolism

   • Pleural effusion

   • Malignancy

6. Cardiovascular Conditions

   • Myocardial infarction

   • Postmyocardial infarction syndrome

   • Postpericardiotomy syndrome

   • Heart failure

   • Cardiothoracic surgery

   • Pneumopericardium due to pericardiocentesis, causing a pleural effusion

   • Pericarditis

7. Cancer (metastasis, lung cancer, lymphoma, mesothelioma)

8. Liver disease

9. Renal failure

10. Trauma/Rib fracture

11. Sickle cell anemia

12. Pancreatitis

13. Inflammatory bowel disease

14. Peritonitis

15. Asbestos

16. Cystic Fibrosis

17. HIV

18. Radiation therapy

19. Drug side effects (methotrexate, penicillin, chemotherapy, isoniazid, hydralazine, nitrofurantoin, and cyclophosphamide)

Pathophysiology [wd1]

1. The parietal pleura lines the chest wall, rib cage, and mediastinum while the visceral pleura covers the lungs

2. Between these layers lies the pleural space filled with pleural fluid and allowing the layers to move freely during respiration

3. The inflamed pleura rub against each other during respiration --> audible pleural friction rub ("walking on fresh snow")

4. Pleuritic chest pain:

   • Sharp

   • Localized

   • Radiation to neck or shoulder

   • Exacerbated by respiratory movements, coughing, or sneezing

Complications [wd1]

• Hypoxia / Respiratory failure

• Pulmonary embolism

• Pleural fibrosis

• Constrictive pleural thickening

• Lung entrapment

• Pneumonia

• Empyema

Epidemiology

Incidence per 100.000 [wd1]

Approach

• Blood test: Troponins, CK-MB, CRP, WBC

• Blood gas

• ECG

• Chest x-ray

• CT thorax

• Ultrasound

• Thoracentesis: flow cytometry and immunohistochemical staining

• Pleural biopsy

• Thoracoscopy

Treatment

Treatment goals: controlling pain and addressing the underlying cause [iss][wd1]

1. Pain:

   • NSAIDs are the mainstay of treatment for pain associated with pleurisy

   • Opioids may be necessary but depress respiratory drive and cough reflexes

   • Corticosteroids in patients with lupus pleuritis

   • Smoking cessation

2. Underlying cause:

   • Viral: self-limited

   • Pneumonia, empyema, or tuberculosis --> Antibiotic

   • Empyema --> Drainage (intrapleural tPA/deoxyribonuclease, chest tube, VATS)

   • Pericarditis and familial Mediterranean fever --> NSAIDs and colchicine

   • Myocarcial infarction: Nitrates, aspirin, antiplatelet medications, anticoagulants, β-blockers, statins and reperfusion (PCI/thrombolysis)

   • Type A aortic dissection --> cardiovascular surgery

   • Pulmonary embolism --> anticoagulation or reperfusion therapy (thrombolytics or embolectomy) for hemodynamically unstable patients

   • Pneumothorax --> catheter/chest tube (needle decompression if tension pneumothorax)

Differential diagnoses

Acute pancreatitis, Adenovirus, Ankylosing spondylitis, Aortic dissection, Asthma, Chronic renal failure, COPD, Costochondritis, Crohn disease, Familial mediterranean fever, Heart failure, Hemothorax, Herpes zoster, Influenza, Lung abscess, Mediastinitis, Mesothelioma, Mononucleosis, Mumps, Myocardial infarction, Myocarditis, Pericarditis, Pleural empyema, Pneumonia, Pneumothorax, Pulmonary embolism, Pulmonary hypertension, Rheumatoid arthritis, Ruptured aortic aneurysm, Sarcoidosis, Sjogren syndrome, Systemic lupus erythematosus, Tuberculosis, Ulcerative colitis