Pleurisy

Pleurisy (or pleuritis) refers to the disease entity characterized by inflammation of the pleura. It classically presents as pleuritic pain. 

Terminology

Pleurisy is often used by medical professionals and laypeople both to refer to the inflammation of the pleura and also the symptoms. Strictly we should reserve pleurisy for the name of the condition, whilst using pleuritic pain for the symptom.

Clinical presentation

Pleurisy typically presents as pleuritic pain, which is typically described as being sharp in nature. Classically pleuritic pain is exacerbated by any action involving a vigorous inspiration/expiration, e.g. sneezing, laughing, coughing, and deep breathing. Chest wall tenderness may be present. Occasionally a pleural rub can be heard. Other signs and symptoms will depend on the underlying etiology.

Rarely, accumulation of pleural fluid is extremely rapid, virtually filling a hemithorax within 24 hours and presenting as respiratory distress. This has been termed "explosive pleuritis" and requires urgent decompression. Often surgical intervention is required. Lymphatic blockage can occur in Streptococcal infections and may be causal ².

Pathology

Etiology

This is a list of etiologies of pleurisy, not for pleuritic pain, which would be different.

• infectious

  • viruses: many, e.g. adenovirus, coxsackie, cytomegalovirus, Epstein-Barr virus, influenza, mumps

  • bacteria: tuberculosis, parapneumonic pleuritis

  • parasites: amoebiasis

• exogenous agents

  • asbestos

  • drugs ¹

    • amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, methysergide, minoxidil, mitomycin, oxyprenolol, practolol, procarbazine

    • medication-induced pleurisy is a distinct phenomenon from the interstitial lung diseases caused by most of these agents

• inflammatory: rheumatoid arthritis, lupus pleuritis, Sjogren syndrome

• cardiac: Dressler syndrome

• gastrointestinal: inflammatory bowel disease, spontaneous bacterial pleuritis

• familial Mediterranean fever

• renal: chronic renal failure

Differential diagnosis

Clearly, in any patient presenting with acute pleuritic pain, it is crucial to exclude the top three diagnoses here.

• pulmonary embolism: most important diagnosis to exclude

• myocardial infarction: pleuritic pain atypical but certainly well-recognized 

• pneumothorax

• pericarditis

• pneumonia

• trauma

• Bornholm disease