Acute Pleuritic- and Thoracic-Related Pain: Clinical Considerations

Benjamin Cole Miller

Megan A. Boudreaux

Erica V. Chemtob

G. Jason Huang

Elyse M. Cornett

Alan David Kaye

Introduction

Pleuritic pain is a type of chest pain that is linked to problems with lung membranes called the pleura. It is often characterized by a sudden sharp, stabbing, or burning pain in the chest when inhaling or exhaling.¹ The lung itself is insensitive to pain so the discomfort associated with respiratory disease must arise from the pleura, tracheobronchial tree, or chest wall.² It is because of this that pleuritic pain can often mimic cardiac, pericardial, abdominal, and musculoskeletal disease.² Thus, patients with any type of chest pain should be worked up with a broad differential as to localize the location of the pain.

Overall, chest pain encompasses ˜1% of primary care visits every year.³ This percent is even higher in settings like the emergency room.² Despite the large number of cases, most are relatively benign with the most common causes being chest wall pain, reflux esophagitis, and costochondritis.³ However, related to severity of the more serious causes of chest pain including pulmonary embolism, myocardial infarction, pericarditis, pneumonia, aortic dissection, and pneumothorax, a workup must focus on ruling these out before a clinician considers more benign causes.⁴ In patients with general chest pain, acute coronary syndrome (ACS), which is a term used to describe a range of conditions associated with reduced flow to the heart such as myocardial infarction and angina, is the most common life-threatening condition seen.⁵ Pulmonary embolisms are another common life-threatening condition that present mostly as pleuritic pain but can also present as chest wall pain depending on the location of the embolism.⁶

Cardiac disease is currently the leading cause of death in the United States, making it all the more vital for physicians to not miss the signs when patients present to them. However, with such a wide differential associated with pleuritic and thoracic pain as well as roughly only 1.5% of the patients presenting to a primary care office with chest pain related to life-threatening causes, it can be difficult for physicians to differentiate serious causes vs more benign causes.³ It is thus important for physicians to quickly as well as accurately take and perform a good history and physical exam.⁷ The time course of the onset of symptoms is the most useful information in the history for narrowing the differential diagnosis as often the most lethal causes of chest pain typically have the most acute onset.¹ During the course of the history and physical, it is vital to be able to identify patients with signs of life-threatening conditions who will need further workup including electrocardiogram (ECG), echocardiography, or urgent transfer to the catheterization laboratory.⁵

Acute pleuritic and thoracic pain are very common forms of pain and can be associated with life-threatening conditions if not recognized and treated appropriately. This type of pain encompasses a wide array of differential diagnoses, making recognition and treatment more difficult.⁷ It is because of this that any type of chest pain should be assessed with a high
degree of suspicion that focuses to rule out the life-threatening causes first and foremost while working up the more benign causes after.²

Etiology Epidemiology Risk Factors Pathophysiology

Etiology and Epidemiology

There are many different causes for chest pain, with each separate etiology requiring different diagnostic studies and treatments. Throughout the course of evaluating a patient with acute chest pain, it is important to first differentiate between emergent and nonemergent causes. Immediately, life-threatening causes of chest pain include myocardial ischemia, thoracic aortic dissection, tension pneumothorax, or pulmonary embolism.⁸

In addition to keeping in mind which diagnoses are the most dangerous, it is important to remember the most common causes of chest pain. It is estimated chest pain is the chief complaint for 5% of all emergency department presentations. Therefore, being able to quickly evaluate a patient and develop a plan is of the utmost importance. The most common causes of emergency department visits for chest pain include ACS, gastrointestinal reflux, and musculoskeletal causes.⁹

According to one study conducted by Freurfaard and colleagues, ACS was the most common cause of emergency department visits where the chief complaint was chest pain. Approximately 31% of all emergency department visits for acute-onset chest pain were related to ACS. Aortic aneurysms, another cardiovascular pathology, accounted for ˜1% of all emergency department visits. Gastrointestinal reflux disease and musculoskeletal pathologies accounted for 30% and 28% of chest pain cases, respectively. In terms of lung pathologies, pulmonary embolism accounted for 2% of presentations and pneumonia/pleuritis also accounted for 2% of emergency department visits.¹⁰

Pathophysiology and Risk Factors

The pathophysiology and various risk factors associated with the differentials for chest pain are important to understand. Obtaining a thorough history to evaluate the patient for risk factors associated with the various etiologies of chest pain will guide the clinician in the quest for a diagnosis. Once the physician determines the diagnosis, understanding the pathophysiology behind the diagnosis will further guide treatment and intervention.

The most common, life-threatening cause of chest pain is ACS. ACS is an umbrella term that is comprised of unstable angina, non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction (STEMI). The key difference between unstable angina and myocardial infarction is based on the presence or absence of cardiac biomarkers in a patient’s serum. Because the ischemic events are transient in angina, cardiac biomarkers such as troponin will not be markedly elevated. However, in myocardial infarction, biomarkers will be elevated, indicating myocardial necrosis has occurred.¹¹ Key risk factors associated with ACS include diabetes, hypertension, hyperlipidemia, and a prior history of MI.⁹

Musculoskeletal causes of chest wall pain are also quite common. The key diagnostic feature of musculoskeletal causes of chest pain is that the pain is reproducible upon palpation. One of the most common causes of musculoskeletal chest pain includes costochondritis, which is inflammation of the costal cartilages. Costochondritis is a self-limited condition that is usually not associated with an identifiable trigger. It is thought that repetitive exercises and activities can contribute to the development of costochondritis. Because of the nonspecific nature of this condition, it is imperative that costochondritis only be included as a diagnosis of exclusion after other, more life-threatening causes of acute chest pain have been ruled out¹² (Table 15.1).

TABLE 15.1 COMMON CAUSES OF ACUTE CHEST PAIN

Organ System	Diagnosis	Pathophysiology	Risk Factors
Cardiac	Acute coronary syndrome	Acute rupture of an atherosclerotic plaque in a coronary artery with subsequent thrombus formation¹¹	Diabetes History of myocardial infarction Family history of heart disease Hypertension Hyperlipidemia⁹
	Thoracic aortic dissection	Inflammation of the aortic wall leading to vessel damage via degeneration of the tunica media and apoptosis of smooth muscle cells, which in turn leads to separation of and blood flow in between the layers of the aortic wall¹³	African American race Male gender Increasing age (peak incidence between 50 and 65 years old) History of connective tissue disorders (Marfan syndrome)¹³
	Myocarditis	Inflammation of the myocardium with subsequent necrosis of myocytes related to an infectious or cardiotoxic agent¹⁴	In the United States: common infectious causes include parvovirus B19 and human herpes virus 6 In developing nations: common infectious causes include rheumatic heart disease secondary to untreated Streptococcus infections or Chagas disease Commonly encountered cardiotoxic agents include alcohol, cocaine, and various pharmaceuticals¹⁴
Pulmonary	Pneumonia	Infection of the lung tissue secondary to viral, fungal, or bacterial causes¹⁵	Recent upper respiratory infection Hospitalization Endotracheal intubation and ventilation Comatose patients (impaired cough reflex) Increased susceptibility in immunodeficiency (HIV and organ transplant recipients) Decreased mucociliary clearance (smokers and Kartagener syndrome)¹⁵
	Pneumothorax	Most often associated with rupture of bullae or blebs Iatrogenic/trauma-related causes¹⁶	Smoking Tall, thin body habitus Pregnancy Marfan syndrome COPD Asthma TB CF Iatrogenic causes (pleural biopsy, positive pressure ventilation) Trauma¹⁶
	Pulmonary embolism	Interference of blood flow in the pulmonary artery and/or its branches secondary to a thrombus that began at another origin (deep veins of the legs)¹⁷	History of deep venous thrombosis or pulmonary embolism Hormone usage (oral contraceptives) Recent surgery Malignancy Prolonged nonambulatory status⁹
Gastrointestinal	Gastrointestinal reflux disease	Decreased tone of the lower esophageal sphincter (LES)¹⁸	Older age Obesity Smoking Anxiety/depression Less physical activity¹⁸
	Peptic ulcer disease	Increased acidity of the stomach leading to destruction of the lining of the stomach extending into the submucosa/muscularis propria¹⁹	H pylori infection NSAID use Zollinger-Ellison syndrome Malignancy Stress African American/Hispanic race²⁰
	Esophageal rupture	Full-thickness tear in the esophageal wall leading to leakage of gastric contents and saliva into the thoracic cavity²¹	History of traumatic injury Foreign body Iatrogenic causes Retching (Boerhaave syndrome)²¹
Musculoskeletal	Costochondritis	Inflammation of costal cartilages¹²	Often idiopathic May be secondary to repetitive exercises Higher frequency in female and Hispanic patients²²
Musculoskeletal	Fibromyalgia	Nonspecific diagnosis of exclusion with diffuse musculoskeletal pain and tenderness not explained by another pathological process²³	Female gender Increased incidence in patients with comorbid rheumatic disease Anxiety/depression²⁴