Overview of Pleurisy

A sharp chest pain that worsens with deep breaths

Pleurisy—also called pleuritis—refers to inflammation of the pleura, which is the membrane that covers your lungs and chest cavity. The main symptom of pleurisy is sharp chest pain that worsens with deep breathing or when coughing.

There are numerous potential causes of pleurisy, some potentially life-threatening, like a heart attack or a blood clot in the lung. Others causes are related to an underlying disease process like infection, cancer, or an autoimmune disorder, such as lupus.

The diagnosis of pleurisy is made through a combination of a medical history, physical examination, and various tests, most notably an imaging test, like a chest x-ray, and/or a procedure that removes fluid from the pleural space (called a thoracentesis).

Treatment of pleurisy is two-fold—pain control followed by treating the underlying condition.

Symptoms of pleurisy
Illustration by Brianna Gilmartin, Verywell

Causes

The pleura is a membrane that contains two thin membranes, one that lines your lungs (called the visceral pleura) and one that lines the inside of your chest cavity (called the parietal pleura).

The visceral and parietal pleura are separated by a small cavity referred to as the pleural cavity, which ordinarily contains three to four teaspoons of pleural fluid. Together, the visceral and parietal pleura act as a cushion, reducing friction on the lungs when you breathe in and out.

Since only the parietal pleura (not the visceral) is innervated by nerves, when it becomes irritated and inflamed, pain arises.

Important Point

There are many potential causes of pleurisy, some very serious, which is why immediate medical attention is warranted for pleuritic (or any) chest pain.

Here are the many possible causes of pleurisy:

Infection

Infection with a virus, such as influenza (the flu), is a common cause of pleurisy. Other types of infections, like those from a bacteria, fungus, or parasite may also cause pleurisy. Sometimes with bacterial causes of pleurisy, a collection of pus forms within the pleural cavity (called an empyema).

Heart and Lung

Various heart and lung conditions, some potentially life-threatening, may be the culprit behind a person's pleurisy. These conditions include:

Autoimmune

Various autoimmune diseases, like systemic lupus erythematosus (SLE or lupus) and rheumatoid arthritis, can cause pleurisy.

Blood (Hemothorax)

Pleurisy may also be caused any condition that causes blood to buildup in the pleural space (called a hemothorax), such as an injury to the chest, chest or heart surgery, or lung or pleural cancer.

Cancer and Other Diseases

Cancers, like lymphoma or mesothelioma, can also cause pleurisy, as can chronic kidney disease, inflammatory bowel disease, pancreatitis, or rare diseases, like Familial Mediterranean Fever (FMF).

Medications

Certain drugs, such as Pronestyl (procainamide) and Apresoline (hydralazine), may cause a lupus-like reaction that leads to pleurisy.

Symptoms

The key symptom of pleurisy is sharp, stabbing, or burning chest pain that occurs with deep breathing, coughing, sneezing, or laughing.

The chest pain may spread to the shoulder or neck, due to inflammation of a nerve (called the phrenic nerve) that innervates the diaphragm.

In addition, breathing difficulties may arise. These difficulties are usually due to excess fluid buildup in the pleural cavity, which can compress or even collapse a lung (called atelectasis).

Besides pain and possible breathing problems, other potential symptoms of pleurisy (depending on the underlying cause) may include:

  • Coughing
  • Fever and chills
  • Unintentional weight loss
  • Cyanosis (blueness of the skin from oxygen deprivation)

Diagnosis

The diagnosis of pleurisy is made by using a combination of a careful history and physical examination, plus lab tests and imaging studies.

Medical History

During the medical history, your doctor will ask you several questions about your symptoms. Answers to these questions can help pinpoint down the "why" or the cause behind your pleurisy.

Here are a few examples of potential questions:

  • Did your chest pain come on suddenly over minutes or did it progress over hours to weeks? (sudden chest pain indicates a potentially serious, life-threatening cause of pleurisy)
  • Does your pain stay in one place or does it move ("radiate") to your shoulder, neck, or back?
  • Are you experiencing problems breathing or any other associated symptoms (e.g., fever, chills, nausea, sweating, cough, or weight loss)?

Physical Exam

During the physical exam, your doctor will listen to your lungs with a stethoscope. While the pleura is smooth, when affected by pleuritis, it becomes rough, rubs together, and often produces a rough, grating sound (called a friction rub).

In addition to a lung exam, your doctor will check your vital signs to see whether or not you have a fever, low blood pressure, fast heart or breathing rate, or low oxygen saturation. These findings can provide clues into your underlying diagnosis.

Then, depending on your doctor's underlying suspicion, other organs, such as your heart, skin, or digestive tract, may be evaluated.

Imaging Tests

The majority of people with pleuritic chest pain will undergo an imaging test.

Such tests may include one or more of the following:

Blood Tests

Various blood tests may also be ordered to sort out the cause of your pleurisy.

Here are just a couple of examples of blood tests your doctor may order:

Electrocardiogram (ECG)

Various abnormalities on an ECG can indicate an underlying heart problem, like a heart attack or pericarditis.

Thoracentesis

If excess fluid is found in the pleural cavity as a result of the underlying condition, a thoracentesis may be done. In this procedure, a fine needle is inserted through the chest into the pleural space to withdraw fluid. In addition to removing the fluid to ease symptoms (e.g., shortness of breath), this fluid can be analyzed in the lab to define the diagnosis (e.g., infection, cancer etc.).

Important Point

A thoracentesis can be both diagnostic and therapeutic.

Biopsy

Less commonly, a pleural biopsy—where a small sample of the inflamed pleura is removed—is performed. This is done to confirm certain diagnoses like tuberculosis or pleural cancer.

Treatment

The first step in treating pleurisy is to diagnose and urgently address potentially life-threatening causes, most notably:

  • Pulmonary embolism
  • Heart attack
  • Pericarditis
  • Aortic dissection
  • Pneumonia
  • Pneumothorax

Once these conditions are ruled out (or promptly addressed), the treatment of pleurisy involves two steps—pain control and treating the underlying condition.

Pain Control

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the primary therapy for easing the pain of pleurisy. If a person does not respond well enough to or cannot tolerate or take NSAIDs, a corticosteroid may be prescribed.

Underlying Condition Management

Once pain is under control, a doctor will address the underlying etiology. For example, for pleurisy related to an infection, antibiotics (bacterial) or antifungals (fungal) may be prescribed.

Drainage of the infected fluid through a thoracentesis may also be performed. Sometimes, if there is a lot of fluid, (or if there is air present, as with a pneumothorax), a chest tube may be inserted into the pleural cavity to effectively remove the fluid (or air).

Other Procedures

Sometimes one or more procedures is warranted, especially for recurrent or malignant (cancerous) pleural fluid build-up:

Some of these procedures include:

  • Pleurodesis: A procedure whereby after the pleural fluid is drained, a chemical is placed in the pleural cavity to help seal the space between the parietal and visceral membranes.
  • Indwelling pleural catheter (IPC): This is a small tube that is placed into the pleural cavity to allow for repeated drainage at home.
  • Pleurectomy: A type of surgery in which part of the affected pleura is removed.

A Word From Verywell

As revealed, pleurisy is a serious medical condition that warrants prompt medical attention.

While being evaluated for your pleurisy, try to remain calm and patient. Even though getting to the bottom of your pain can be a bit tricky and tedious, once the culprit is discovered, you can move forward with a treatment plan.

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