Pleuritic chest pain
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Pleuritic Chest Pain: Definition and Key Characteristics
Pleuritic chest pain is a sharp, well-localized pain in the chest that worsens with inspiration or coughing. It is typically somatic in nature, arising from irritation of the pleura, but can also be caused by issues in the chest wall or pericardium. The pain is usually sudden and intense, described as stabbing or burning, and is mediated by fast-conducting nerve fibers, making it distinct from other types of chest pain 12.
Common and Life-Threatening Causes of Pleuritic Chest Pain
The most common serious cause of pleuritic chest pain is pulmonary embolism, which is found in 5% to 21% of patients presenting to emergency departments with this symptom. Other potentially life-threatening causes include tension pneumothorax, pneumonia, empyema, acute pericarditis, myocardial infarction, and aortic dissection. These conditions must be considered and ruled out early in the diagnostic process due to their severity and potential for rapid deterioration 12345910.
Diagnostic Approach and Clinical Evaluation
A thorough history and physical examination are essential for evaluating pleuritic chest pain. Key diagnostic tools include chest radiography, electrocardiography (ECG), and laboratory tests such as troponin assays. For suspected pulmonary embolism, validated clinical decision rules (like the Wells score) and additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography are recommended. When aortic dissection is suspected, contrast-enhanced CT angiography is the imaging modality of choice, and point-of-care ultrasound can be a useful adjunct 23459.
Infectious and Unusual Causes
Viral infections are common causes of pleuritic chest pain, with pathogens such as coxsackievirus, influenza, and respiratory syncytial virus frequently implicated. Bacterial infections leading to pneumonia or empyema can also present with pleuritic pain. Rare causes, such as torsion of extralobar pulmonary sequestration, should be considered in atypical cases or when initial investigations are inconclusive 258.
Case Examples and Special Considerations
Case reports highlight the diverse presentations of pleuritic chest pain. For example, a young adult with Wellens syndrome presented with pleuritic pain and was found to have significant coronary artery occlusion, underscoring the need to consider cardiac causes even in younger patients. Another case involved a patient with aortic dissection presenting with pleuritic pain, demonstrating the importance of rapid imaging and intervention. Additionally, persistent or worsening symptoms, especially in patients with risk factors or abnormal imaging, warrant further investigation to exclude serious underlying pathology 7910.
Management Strategies
Treatment of pleuritic chest pain depends on the underlying cause. For viral or nonspecific pleuritic pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for symptom relief. When a specific diagnosis is made, targeted therapy is essential—antibiotics for bacterial infections, anticoagulation for pulmonary embolism, or surgical intervention for conditions like aortic dissection or torsion of pulmonary sequestration. Follow-up imaging may be necessary in certain cases, such as pneumonia in older adults or smokers, to ensure resolution 2589.
Conclusion
Pleuritic chest pain is a symptom with a broad differential diagnosis, ranging from benign viral infections to life-threatening emergencies like pulmonary embolism and aortic dissection. Prompt recognition, thorough evaluation, and appropriate use of diagnostic tools are critical for identifying the underlying cause and guiding effective management. Early intervention in serious cases can be lifesaving, while supportive care is sufficient for more benign etiologies 123458910.
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