Pleurisy, also known as Pleuritis, is a condition of the lungs in which the pleura (lining of the lungs that separates them from the chest wall) becomes inflamed. It presents with sharp chest pain, i.e., pleuritic pain that worsens with breathing (or coughing). There can be multiple causes of pleural inflammation including infections (viral or bacterial), lung pathologies, auto-immune disorders, etc. The severity of the disease can vary from mild to very serious. Viral infections are the most common causes of pleurisy. Causes like pulmonary embolism are life-threatening and need immediate medical attention. Treatment depends on the underlying cause of the swelling. However, draining out excess fluid from the pleura is common in all cases.

Pleurisy Symptoms

Chest Pain:

The chief complaint of patients with pleurisy is severe chest pain. Pleuritic chest pain is sharp, intense, and has a sudden onset. Several patients report stabbing pain or burning sensations in the chest. The symptoms get exacerbated during lung movements, i.e., inhaling and exhaling. Activities that put pressure on the lungs (such as deep breathing and coughing) also worsen the pain.¹

Breathing Difficulties:

Pain in inhaling and exhaling makes breathing troublesome. Therefore, patients also report breathing issues with the inflammatory disorder. The initial symptoms of pleurisy may resemble COVID-19 infection. According to a clinical report, a 48-year-old male presented to the ER with acute onset pleuritic pain and low oxygen levels, i.e., hypoxemia. The patient subsequently developed a fever and shortness of breath. Viral infection was found to be the cause of pleurisy.²
Rarely, patients can also suffer from cough as a result of pleuritis. Some patients also report fatigue as a consequence of chest inflammation. Systemic lupus erythematosus (SLE)-induced pleurisy can present with pain and fatigue.³

Pleurisy Causes

Idiopathic:

In around 30-40% of cases, the cause of pleurisy is unknown, i.e., idiopathic pleurisy. Patients present with reduced vital capacity of the lungs and chest pain. Reports suggest that the majority of such patients (82%) can achieve complete resolution of symptoms with proper treatment. However, 17% reported a recurrence of pleurisy over time.⁴

Lung Pathologies:

Multiple pathologies of the lungs can contribute to the swelling of the lungs’ layers.

Cancer

Evidence shows that the correlation between cancer and pleurisy is weak. However, malignancies of the lungs can lead to abnormalities in the plurae. Reports suggest that 5% of cases with idiopathic pleuritis were diagnosed with an underlying malignancy during a 3-year follow-up study period.⁵
In another retrospective review of pleurisy cases, 42% of cases with non-specific pleuritis suffered from malignancy.⁶

Cancers arising in the mesothelium (pleural layers) are called malignant pleural mesothelioma. This aggressive tumor tends to cause swelling of the pleura. Thus, desmoplastic mesothelioma is sometimes referred to as fibrous pleurisy.⁷

Asbestosis

Exposure to asbestos can cause lung disease, which contributes to asbestos pleurisy. The disease is known to cause fibrosis, pleural thickening, and inflammation.⁸ Hemothorax and pneumothorax can also cause pleuritis. As per estimates 90% of patients suffering from pneumothorax experience severe pleuritic pain.

Infection:

The most common cause of pleurisy is infection. You can develop pleurisy due to a bacterial or viral infection.

Bacterial Infections

Tuberculous pleurisy is a highly prevalent lung condition in Korea. Mycobacterium tuberculosis infection causes pleurisy by entering the pleural space and interacting with the T-cells. It is an acute illness characterized by fever, weight loss, night sweats, dyspnea, malaise, etc.⁹
MRSA infection (Staph aureus) can cause pleurisy, especially in hospitalized patients. Pleurisy induced by Brucella infection is rare but possible. It presents with fever, chest pain, and shortness of breath.¹⁰
Mediterranean spotted fever, legionellae, and empyema infections can also be the cause of pleurisy.

Viral Infections

Pathogens like the influenza virus can induce pleurisy in patients. Other viruses that can cause the problem include coxsakievirus, Epstein-Barr, cytomegalovirus, adenovirus, and respiratory syncytial virus.

Community-Acquired Pneumonia (CAP)

Pneumonia is a type of infectious disease that causes inflammation of the air sacs. Community-acquired refers to infections acquired outside of a hospital. A wide variety of pathogens including bacteria, viruses, and fungi can cause CAP. In general, pleuritis ensues when there is a significant inflammation of lung tissues. Patients experience pleuritic chest pain, dyspnea, purulent sputum, and unexplained weight loss.¹¹
Researchers have found a link between childhood pneumonia and pleurisy, which leads to poor lung function.¹²

Pulmonary Embolism:

Pleurisy may indicate a serious underlying lung condition that may be life-threatening. Pulmonary embolism is a condition in which a blood clot blocks the blood supply in a lung artery, which leads to rapid surges in the blood pressure of pulmonary arteries and reduces the oxygen content of the blood. Ultimately, this can cause heart failure and even death. Pleurisy due to pulmonary embolism occurs in about 5-21% of cases. Approximately 75% of pulmonary embolism patients report pleuritic chest pain.¹³
According to reports, pleurisy may serve as an initial symptom of a pulmonary embolism that can allow doctors to effectively treat the dangerous condition.¹⁴

Auto-Immune Disorders:

Inflammation of the pleura can also be a symptom of auto-immune diseases. Pleural involvement is seen in around 20% of autoimmune cases. Auto-immune disorders in which pleurisy is seen include¹⁵:

Rheumatoid arthritis (RA)
Systemic lupus erythematosus (SLE)
Scleroderma
Mixed connective tissue disease
Ankylosing spondylitis
Sjogren’s syndrome
Wegener’s granulomatosis
Familial Mediterranean fever (FMF)

In a case study, bilateral pleuritis was concluded to be an initial symptom of systemic lupus erythematosus.¹⁶ However, pleural inflammation is typically a late presentation of rheumatoid arthritis, which is present in about 50-70% of RA cases.¹⁷

Chest Surgery Or Trauma:

Trauma or chest surgery can land you in trouble. Studies show that blunt trauma and chest wall injuries can induce pleuritic chest pains.¹⁸

Medications:

Cardiovascular, anti-tuberculous, and chemotherapeutic drugs can also initiate pleural inflammation. Medications like hydralazine (heart medicine), procainamide (anesthetic), isoniazid (anti-tuberculous), methotrexate (immune-suppressant), etc can cause pleurisy. Moreover, patients taking atezolizumab for small-cell lung cancer reported developing recurrent pleural effusion and chronic pleuritis as a side effect of the drug.¹⁹
Other health conditions that can cause pleurisy include inflammatory bowel disease, chronic kidney disease, and sickle cell disease.

Pleurisy Risk Factors:

The following individuals are at a greater risk of developing pleuritis:

Old age (above 65)
Autoimmune disorder patients
Cancer patients
People taking medications for heart issues, tuberculosis, and cancer
Individuals who have sustained chest injuries or undergone surgery

Pleurisy Transmission

Is Pleurisy Contagious?

Pleurisy is a presentation of different underlying conditions. Pleuritis developing due to embolism, cancer, or auto-immune disorders is not contagious. However, while viruses and bacteria causing the condition are transmissible, the condition itself is not contagious.

Pleurisy Diagnosis

For pleuritis diagnosis, your doctor will take a complete history of the symptoms. Important questions in this regard include location of pain, any changes in pain intensity with breathing, etc. During the physical examination, the doctors place the stethoscope on the patient’s chest and listen for pleura rubbing against others, a disease characteristic called “pleural friction rub”. These sounds resemble “squeaking shoes on a wet surface” or “walking on fresh snow“.²⁰
Your healthcare provider may also order some diagnostic tests.

Imaging Tests

Your provider may order multiple radiographic scans of your lungs such as X-rays, ultrasounds, and CT scans to detect pleural inflammation. X-rays aid in providing clues about fluid accumulation in the pleura (pleural effusion) and signs of infection (pneumonia) but not pleurisy per se.

A medic examining
chest X-ray to detect pleurisy

Ultrasound locates the fluid and pleural masses while CT scan provides greater clarification of lung structures.

Blood Tests

A detailed analysis of the blood helps reveal signs of infection and inflammation in the body. Specific tests like auto-antibodies and rheumatoid factor aid in diagnosing autoimmune disorders.

Electrocardiogram

An electrocardiogram (ECG/EKG) is an important test because it reveals the functioning of the heart. The tests help in ruling out serious conditions like pulmonary embolism.

Thoracentesis

In this type of diagnostic test, the health professional withdraws pleural fluid from your lungs via a small, fine needle. The fluid is then sent to a lab to check for signs of infection (or other causes of pleurisy).

Thoracoscopy

Your doctor will look inside your lungs via a small camera on a tube (with light attached to it).

Pleurisy Treatment

The main aim of the treatment is to alleviate pain and address the underlying cause.

Painkiller Medicines

For pain management, doctors prescribe over-the-counter pain-killer medicines (NSAIDs and corticosteroids). Indomethacin is the most commonly prescribed painkiller for pleurisy. Oral corticosteroids are reserved for severe cases (and lupus pleuritis) only because they cause respiratory depression. Smoking cessation is also advised. If suffering from pericarditis or Familial Mediterranean fever, your doctor might also recommend taking colchicine.

Antimicrobials

Doctors advise antibiotics, antiviral, and antifungal drugs to manage respective infectious conditions like tuberculosis and pneumonia, etc.

Fluid Draining

Patients undergo catheter thoracostomy (chest tube) to drain out excess pleural fluid. It’s a minimally invasive procedure in which the doctor places a thin tube into your chest wall (within the pleural space) to drain the extra fluid.

Disease-Modifying Antirheumatic Drugs (DMARDs)

Rheumatologists prescribe DMARDs to manage autoimmune disorders like RA, SLE, etc. This helps control pleural effusion and inflammation.

Pleurisy Recovery Time

There is no specific recovery time as pleurisy is the outcome of different conditions. However, in the case of viral pleuritis, the symptoms go away (on their own) within a few days to weeks time. On the other hand, bacterial pleuritis cases require long-term hospitalizations and appropriate treatment. Many RA patients report resolution of symptoms within 3 months.

Complications Associated With Pleurisy

Several different conditions coexist with pleurisy. The inflammation of the pleura can also lay the foundation for further health complications including pleural effusion, atelectasis (partial lung collapse), and empyema (collection of pus around the lung tissues).
Therefore, you should not ignore your chest pain and get it checked as soon as possible!

Final Word

Pleurisy or pleuritis is a lung condition in which the pleura of the lungs gets inflamed. This leads to severe, sharp pain in the chest which worsens with breathing. The swelling of the pleura is attributed to multiple causes such as pulmonary embolism, infection (bacterial/viral), pneumonia, cancer, lung pathologies (pneumothorax, etc.), and auto-immune diseases (RA, SLE, FMF, etc.). Treatment involves painkillers (like indomethacin) for pleuritic chest pain. Doctors advise antimicrobial medications in case of underlying infection and DMARDs for auto-immune disease control. A catheter thoracostomy is done to drain excess pleural fluid from the pleura via a thin tube.

Refrences

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Pleurisy: Causes, Symptoms & Treatment Options

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