Recommendations for Treatment of Pleurisy

May 8, 2007 — A review published in the May 1 issue of American Family Physician describes diagnosis and treatment strategies for pleurisy. The authors recommend history, physical examination, and chest radiography for all patients with pleuritic chest pain.

"Pleurisy is inflammation of the parietal pleura that typically results in characteristic pleuritic pain and has a variety of possible causes," write Sara M. Kass, CDR, MC, USN, from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and colleagues. "It is more precise to use the term 'pleurisy' for the condition and 'pleuritic pain' to describe the symptom. Pleuritic pain is a key feature of pleurisy; therefore, this article reviews the physiology and classic characteristics of pleuritic pain, focusing on the presentation and diagnosis of the patient and the management of various causes of pleurisy."

The causes of pleuritic pain range from benign, self-limited conditions to life-threatening diseases such as pulmonary embolism, which is found in 5% to 20% of patients presenting to the emergency department with pleuritic pain. Other clinically significant diagnoses associated with pleuritic pain include pericarditis, pneumonia, myocardial infarction, and pneumothorax. These must be ruled out with appropriate evaluations.

Once pulmonary embolism, myocardial infarction, pneumothorax, pericarditis, and pneumonia have been ruled out as the cause of pleuritic chest pain, the differential diagnosis of pleurisy includes the following:

Cardiac causes: post–cardiac injury syndrome, post–myocardial infarction syndrome (Dressler's syndrome), and postpericardiotomy syndrome (postcommissurotomy syndrome).

Toxic exposure: asbestosis and drugs including amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, methysergide, minoxidil, mitomycin, oxyprenolol, practolol, procarbazine, and sclerotherapeutic agents. Drugs that may cause lupus pleuritis include hydralazine, procainamide, and quinidine.

Gastrointestinal causes: inflammatory bowel disease and spontaneous bacterial pleuritis.

Genetic causes: familial Mediterranean fever.

Hematologic-oncologic causes: malignancy and sickle cell disease.

Infectious causes: viral (adenovirus, Coxsackie viruses, cytomegalovirus, Epstein-Barr virus, influenza, mumps, parainfluenza, and respiratory syncytial virus), bacterial (Mediterranean spotted fever and parapneumonic or tuberculous pleuritis), and parasitic (amebiasis and paragonimiasis).

Inflammatory reactive causes: eosinophilic pleuritis.

Renal causes: chronic renal failure and renal capsular hematoma.

Rheumatologic causes: lupus pleuritis, rheumatoid pleuritis, and Sjögren's syndrome.
All patients with pleuritic chest pain should be evaluated with history, physical examination, and chest radiography. Electrocardiography is helpful, particularly when myocardial infarction, pulmonary embolism, or pericarditis is suspected. When these significant diagnoses associated with pleuritic pain have been excluded, the diagnosis of pleurisy remains as a diagnosis of exclusion.

Among the numerous causes of pleurisy, viral pleurisy is the most common. Selected patients may benefit from additional diagnostic testing looking for other etiologies.

In addition to specific treatments targeting the underlying cause, treatment of pleurisy typically consists of pain management with nonsteroidal anti-inflammatory drugs (NSAIDs).

Specific key recommendations for practice are as follows:

A thorough history and physical examination should be performed to diagnose or exclude life-threatening causes of pleuritic pain before making a diagnosis of pleurisy.

Pulmonary embolism is the most frequently observed life-threatening cause of pleuritic chest pain, and it should be considered in all patients with pleuritic pain. Evaluation should include validated clinical decision rules, D-dimer testing, and imaging studies as needed.

Patients with pleuritic pain should undergo chest radiography to diagnose or rule out underlying pneumonia.

NSAIDs should be prescribed for pleuritic pain.
The current review points out that NSAIDs are first-line treatment for patients with post–cardiac injury syndrome, and corticosteroids are reserved for those who are intolerant of or refractory to NSAIDs. Oral corticosteroids are recommended for patients with pleuritis secondary to lupus, but they have not been shown to affect the course of rheumatoid pleuritis.

Although tuberculous pleuritis is associated with inflammation and fibrosis, the role of systemic corticosteroids in treating tuberculous pleuritis is controversial. A small number of randomized and quasi-randomized studies with patients who were not infected with HIV have shown no effect of steroids on the primary outcome of an alteration in residual lung function. These studies did show a nonsignificant trend toward benefit, in terms of decreased number of patients with pleural effusions, thickening, or adhesions, but evidence is insufficient to determine whether steroids are an effective treatment.

The authors have disclosed no relevant financial relationships.

Am Fam Physician. 2007;75:1357-1364.

Source: http://www.medscape.com/viewarticle/556185?src=mp