Pleurisy

Classification and external resources
Figure A shows the location of the lungs, airways, pleura, and diaphragm. The inset image shows a detailed view of the two pleural layers and pleural space. Figure B shows lungs with pleurisy and pneumothorax. The inset image shows a detailed view of an infected lung with thickened and inflamed pleural layers.
ICD-10	J90, R09.1
ICD-9	511
DiseasesDB	29361
MedlinePlus	001371
MeSH	D010998

Pleurisy (also known as pleuritis) is an inflammation of the pleura, the lining surrounding the lungs.^[1] There are many possible causes of pleurisy but viral infections spreading from the lungs to pleural cavity are the most common.^[2] The inflamed pleural layers rub against each other every time the lungs expand to breathe in air.^[3] This can cause sharp pain when breathing, also called pleuritic chest pain.^[4][5]

Contents

Symptoms

The defining symptom of pleurisy is a sudden sharp, stabbing, burning or dull pain in the right or left side of the chest during breathing, especially when one inhales and exhales.^[6] It feels worse with deep breathing, coughing, sneezing, or laughing. The pain may stay in one place, or it may spread to the shoulder or back.^[7] Sometimes, it becomes a fairly constant dull ache.^[8]
Depending on its cause, pleuritic chest pain may be accompanied by other symptoms:^[9]

• Dry cough
• Fever and chills
• Rapid, shallow breathing
• Shortness of breath
• Rapid pulse
• Sore throat followed by pain and swelling in the joints
• Ventricular tachycardia

Causes

Pleural linings and space (marked in blue)

Pleural space can be invaded by fluid, air, and particles from different parts of the body which fairly complicates the diagnosis.^[9][10] Viral infection (coxsackievirus, RSV, CMV, adenovirus, EBV, parainfluenza, influenza) is the most common cause of pleurisy. However, many other different conditions can cause pleuritic chest pain:

• Aortic dissections
• Autoimmune disorders such as systemic lupus erythematosus (or drug-induced lupus erythematosus) and rheumatoid arthritis
• Bacterial infections associated with pneumonia and tuberculosis
• Chest injuries (blunt or penetrating)
• Familial Mediterranean fever, an inherited condition that often causes fever and swelling in the abdomen or the lungs
• Fungal or parasitic infections
• Heart surgery, especially coronary-artery bypass grafting
• Cardiac problems (ischemia, pericarditis)
• Inflammatory bowel disease
• Lung cancer and lymphoma
• Other lung diseases like Cystic Fibrosis, sarcoidosis, asbestosis, lymphangioleiomyomatosis, and mesothelioma
• Pneumothorax
• Pulmonary embolisms, which are blood clots that enter the lungs

When the space between two layers of pleura starts to fill with fluid in a case of pleural effusion, it can ease the chest pain, but instead creates a shortness of breath, since the lungs need room to expand during breathing. Some cases of pleuritic chest pain are idiopathic, which means that the exact cause cannot be determined.

Diagnosis

A diagnosis of pleurisy or another pleural condition is based on a medical history, physical examinations, and diagnostic tests.^[9] The goals are to rule out other sources of the symptoms and to find the cause of the pleurisy so that the underlying disorder can be treated.

Physical examination

A doctor uses a stethoscope to listen to the breathing. This method detects any unusual sounds in the lungs. A person with pleurisy may have inflamed layers of the pleura that make a rough, scratchy sound as they rub against each other during breathing. This is called pleural friction rub.

Diagnostic tests

Depending on the results of the physical examination, diagnostic tests are sometimes performed.

Chest x-ray

A chest x-ray takes a picture of the heart and lungs. It may show air or fluid in the pleural space. It also may show the cause (e.g. pneumonia, a fractured rib, or a lung tumor) of the pleurisy.
Sometimes an x-ray is taken while lying on the painful side. This may show fluid, as well as changes in fluid position, that did not appear in the vertical x-ray.

Blood Test

Blood tests can detect bacterial or viral infections, pneumonia, rheumatic fever, a pulmonary embolism, or lupus.

ECG

Electrocardiography test can determine if a heart condition contributes to the symptoms.

Ultrasound

Ultrasonography uses sound waves to create an image. It may show where fluid is located in the chest. It also can show some tumors. Although ultrasound may detect fluid around the lungs, also known as a pleural effusion, sound waves cannot penetrate bone. Therefore, an actual picture of the lungs cannot be obtained with ultrasonography.

Computed tomography (CT) scan

A CT scan provides a computer-generated picture of the lungs that can show pockets of fluid. It also may show signs of pneumonia, a lung abscess, or a tumor.

Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI), also called nuclear magnetic resonance (NMR) scanning, uses powerful magnets to show pleural effusions and tumors.

Arterial Blood Gas

In arterial blood-gas sampling, a small amount of blood is taken from an artery, usually in the wrist. The blood is then checked for oxygen and carbon-dioxide levels. This test shows how well the lungs are taking in oxygen.

Thoracentesis

The illustration shows a person undergoing thoracentesis. The person sits upright and leans on a table. Excess fluid from the pleural space is drained into a bag.

Once the presence of an excess fluid in the pleural cavity, or pleural effusion, is suspected and location of fluid is confirmed, a sample of fluid can be removed for testing.^[11] The procedure to remove fluid in the chest is called a diagnostic thoracentesis.^[12] The doctor inserts a small needle or a thin, hollow, plastic tube in the chest wall and withdraws fluid.^[13]
Thoracentesis can be done in the doctor's office or at the hospital. Ultrasound is used to guide the needle to the fluid that is trapped in small pockets around the lungs.
Thoracentesis usually does not cause serious complications. Generally, a chest x-ray is done after the procedure to evaluate the lungs. Possible complications of thoracentesis include the following:

• Bleeding and bruising where the needle went in. In rare cases, bleeding may occur in or around the lung. The doctor can use a chest tube to drain the blood. In some cases, surgery is needed.
• Infection where the needle went in
• Injury to the liver or spleen (in rare cases)
• Pain
• Pneumothorax, or buildup of air in the pleural space, with a collapsed or partially collapsed lung. Sometimes air comes in through the needle or the needle makes a hole in the lung. Usually, a hole will seal itself. But sometimes air can build up around the lung and make it collapse. A chest tube can remove the air and let the lung expand again.

The lung fluid is examined under a microscope and is evaluated for the presence of chemicals and for its color and texture. The degree of clarity is an indicator of infection, cancer, or other conditions that may be causing the buildup of fluid or blood in the pleural space.

Biopsy

If tuberculosis or cancer is suspected, a small piece of the pleura may be examined under a microscope to make a definitive diagnosis. This is called a biopsy.
Several approaches to taking tissue samples are available

1. Insertion of a needle through the skin on the chest to remove a small sample of the outer layer of the pleura.
2. Insertion of a small tube with a light on the end (endoscope) into tiny cuts in the chest wall in order to visualize the pleura. Small pieces of tissue can be biopsied though the endoscope.
3. Removal of a sample of the pleura through a small cut in the chest wall. This is called an open pleural biopsy. It is usually done if the sample from the needle biopsy is too small for an accurate diagnosis.

Treatment

Treatment has several goals:^[9]

• Relief of symptoms
• Removal of the fluid, air, or blood from the pleural space
• Treatment of the underlying condition

Procedures

If large amounts of fluid, air, or blood are not removed from the pleural space, they may cause the lung to collapse.
The surgical procedures used to drain fluid, air, or blood from the pleural space are as follows:

• During thoracentesis, a needle or a thin, hollow, plastic tube is inserted through the ribs in the back of the chest into the chest wall. A syringe is attached to draw fluid out of the chest. This procedure can remove more than 6 cups (1.5 litres) of fluid at a time.
• When larger amounts of fluid must be removed, a chest tube may be inserted through the chest wall. The doctor injects a local painkiller into the area of the chest wall outside where the fluid is. A plastic tube is then inserted into the chest between two ribs. The tube is connected to a box that suctions the fluid out. A chest x-ray is taken to check the tube's position.
• A chest tube also is used to drain blood and air from the pleural space. This can take several days. The tube is left in place, and the patient usually stays in the hospital during this time.
• Sometimes the fluid contains thick pus or blood clots, or it may have formed a hard skin or peel. This makes it harder to drain the fluid. To help break up the pus or blood clots, the doctor may use the chest tube to put certain medicines into the pleural space. These medicines are called fibrinolytics. If the pus or blood clots still do not drain out, surgery may be necessary.

Medications

A couple of medications are used to relieve pleurisy symptoms:

• Paracetamol (acetaminophen) or anti-inflammatory agents to control pain and decrease inflammation. Only indomethacin (brand name Indocin) has been studied with respect to relief of pleurisy.^[14]
• Codeine-based cough syrups to control a cough

There may be a role for the use of corticosteroids (for tuberculous pleurisy), tacrolimus (Prograf) and methotrexate (Trexall, Rheumatrex) in the treatment of pleurisy. Further studies are needed.

Lifestyle changes

The following may be helpful in the management of pleurisy:

• Lying on the painful side may be more comfortable
• Breathing deeply and coughing to clear mucus as the pain eases. Otherwise, pneumonia may develop.
• Getting rest

Treating the cause

Ideally, the treatment of pleurisy is aimed at eliminating the underlying cause of the disease.

• If the pleural fluid is infected, treatment involves antibiotics and draining the fluid. If the infection is tuberculosis or from a fungus, treatment involves long-term use of antibiotics or antifungal medicines.
• If the fluid is caused by tumors of the pleura, it may build up again quickly after it is drained. Sometimes anti-tumor medicines will prevent further fluid buildup. If they don't, the doctor may seal the pleural space. This is called pleurodesis. Pleurodesis involves the drainage of all the fluid out of the chest through a chest tube. A substance is inserted through the chest tube into the pleural space. This substance irritates the surface of the pleura. This causes the two layers of the pleura to squeeze shut so there is no room for more fluid to build up.
• Chemotherapy or radiation treatment also may be used to reduce the size of the tumors.
• If congestive heart failure is causing the fluid buildup, treatment usually includes diuretics and other medicines.

The treatment for pleurisy depends on its origin and is prescribed by a physician on a base of an individual assessment.^[15] Paracetamol (acetaminophen) and amoxicillin, or other antibiotics in case of bacterial infections, are common remedies dispensed by doctors to relieve the initial symptoms and pain in the chest, while viral infections are self-limited. Non-steroidal anti-inflammatory drugs (NSAIDs), preferably indometacin, are usually employed as pain control agents.^[9]

Alternative treatments

A number of alternative or complementary medicines are being investigated for their anti-inflammatory properties, and their use in pleurisy. At this time, clinical trials of these compounds have not been performed.
Extracts from the Brazilian folk remedy Wilbrandia ebracteata ("Taiuia") have been shown to reduce inflammation in the pleural cavity of mice.^[16][17] The extract is thought to inhibit the same enzyme, cyclooxygenase-2 (COX-2), as the non-steroidal anti-inflammatory drugs.^[17] Similarly, an extract from the roots of the Brazilian Petiveria alliacea plant reduced inflammation in a rat model of pleurisy.^[18] The extract also reduced pain sensations in the rats. An aqueous extract from Solidago chilensis has been shown to reduce inflammation in a mouse model of pleurisy.^[19]
Pleurisy root Asclepias tuberosa is another example of a herbal solution for this inflammation.

Related problems

Pleurisy is often associated with complications that affect the pleural space.

Pleural effusion

In some cases of pleurisy, excess fluid builds up in the pleural space. This is called a pleural effusion. The buildup of fluid usually forces the two layers of the pleura apart so they don't rub against each other when breathing. This can relieve the pain of pleurisy. A large amount of extra fluid can push the pleura against the lung until the lung, or a part of it, collapses. This can make it hard to breathe.
In some cases of pleural effusion, the extra fluid gets infected and turns into an abscess. This is called an empyema.
Pleural effusion involving fibrinous exudates in the fluid may be called fibrinous pleurisy. It sometimes occurs as a later stage of pleurisy.
A person can develop a pleural effusion in the absence of pleurisy. For example, pneumonia, heart failure, cancer, or a pulmonary embolism can lead to a pleural effusion.

Pneumothorax

Air or gas also can build up in the pleural space. This is called a pneumothorax. It can result from acute lung injury or a lung disease like emphysema. Lung procedures, like surgery, drainage of fluid with a needle, examination of the lung from the inside with a light and a camera, or mechanical ventilation, also can cause a pneumothorax.
The most common symptom is sudden pain in one side of the lung and shortness of breath. A pneumothorax also can put pressure on the lung and cause it to collapse.
If the pneumothorax is small, it may go away on its own. If large, a chest tube is placed through the skin and chest wall into the pleural space to remove the air.

Hemothorax

Blood also can collect in the pleural space. This is called hemothorax. The most common cause is injury to the chest from blunt force or surgery on the heart or chest. Hemothorax also can occur in people with lung or pleural cancer.
Hemothorax can put pressure on the lung and force it to collapse. It also can cause shock, a state of hypoperfusion in which an insufficient amount of blood is able to reach the organs.

Prognosis

Pleurisy and other disorders of the pleura can be serious, depending on what caused them. Generally, pleurisy treatment has an excellent prognosis, but if left untreated it can cause severe complications. For example, a resulting pulmonary heart disease cor pulmonale, which manifests itself with an inflammation of the arms and legs, can lead to heart failure. If the conditions that caused the pleurisy or other pleural disorders were adequately diagnosed and treated early, one can expect a full recovery. Help of a pulmonologist (respiratory physician in the U.K. and Australia) may be enlisted to address the underlying course of a pleurisy and chart post-illness rehabilitation.

Notable cases

• Gaius Marius, a Roman general and statesman, according to Plutarch died of the disease in 86 BC.^[20]
• Flavius Constantius III, a co-emperor of the Western Roman Empire, died of pleurisy according to Sidonius Apollinaris on 2 September 421 AD.^[21]
• Charlemagne, known as the father of Europe for reuniting much of the Roman Empire, died in 814 of pleurisy.^[22]
• Hernán Cortés died on December 2, 1547, from a case of pleurisy at the age of 62.
• Catherine de' Medici, sometimes described as a "wife of one King and mother of three others", died from pleurisy in January 1589 at age 69.^[23]
• Giovanni Pierluigi da Palestrina, Renaissance composer died in 1594 from pleurisy in Rome, Italy.
• Benjamin Franklin developed fever and chest pain in 1790 at the age of 84. He spent ten days in bed having severe cough and difficulty breathing. He died after an abscess in his lungs burst from what is believed to be a case of pleurisy.^[24]
• Adelaide of Saxe-Meiningen, wife of King William IV of the United Kingdom, contracted pleurisy in 1819, it is, in part, blamed for her difficulty in bearing children throughout that year.
• Juan O'Donoju, last viceroy of the Spanish colony of New Spain (Mexico), died of pleurisy on October 8, 1821.^[25]
• Francis Scott Key died in 1843 at the home of his daughter Elizabeth Howard in Baltimore from pleurisy.^[26]
• William Wordsworth, the English poet, died of pleurisy at age 80 on 23 April 1850.^[27]
• Dominic Savio, Italian Saint, became ill and died in March 1857 at the age of 14 possibly from pleurisy.^[28]
• Tad Lincoln, the fourth and youngest son of Abraham Lincoln, had difficulty breathing when lying down and had to sleep sitting in a chair, and probably died of pleuristic attack, which was believed to be tubercular in origin, in Chicago in 1871 at age 18.^[29]
• Prince Alemayehu, son of Emperor Tewodros II of Ethiopia died in Britain of pleurisy in 1879 at age 18.
• Devil Anse Hatfield, a leader of the Hatfield clan and the driving force of the infamous Hatfield–McCoy feud, had a bout of pleurisy in the 1890s (probably 1897).^[30]
• Frank C. Stanley, former Peerless Quartet member, died of pleurisy at the age of 41 on 12 December 1910 at his home in Orange.^[31]
• Mahatma Gandhi suffered from pleurisy during the First World War, while he was in London.^[32]
• Enrico Caruso was struggling with pleurisy in the winter of 1920-1921, which contributed to his premature death.^[33][34]
• Eli Bowen, a circus performer known as "The Legless Wonder", or "The Legless Acrobat", died May 2, 1924 in Coney Island of pleurisy days before a scheduled performance for The Dreamland Circus at age 79.^[35]
• Erik Satie, French composer, died from pleurisy at l'Hôpital St. Joseph on 1 July 1925.^[36]
• Rudolph Valentino, an international movie star, died in August 1926 from pleurisy at age 31.^[37]
• Alvin Kraenzlein was the first athlete to win four Olympic titles in a single event at the 1900 Summer Olympics in Paris. He suffered from bouts of pleurisy at the end of 1927 and died from a related complication early 1928 at the age of 51.^[38]
• Thomas Hardy, English novelist and poet, became ill with pleurisy and died of related causes in 1928 at age 87.^[39]
• Anna Pavlova, one of the world's most famous ballerinas, on January 23, 1931 unexpectedly died of pleurisy at age 49 at the Hotel des Indes in The Hague.^[40]
• Florenz Ziegfeld, Jr., a Broadway impresario, who was credited with staging several hit musicals including Show Boat (1927), died on July 22, 1932 of pleurisy after a lung infection at age 65.^[41]
• Kenji Miyazawa, a Japanese poet and writer, suffered from chronic pleurisy and died of pneumonia in September 1933 at age 37.^[42]
• Sir Robert Chesebrough, inventor of Vaseline, suffered pleurisy in his 50s and is said to have employed a creative method of treatment of pleurisy by rubbing his whole body with petroleum jelly.^[43]
• Colonel Edward Mandell House died on March 28, 1938 in New York City, following a bout with pleurisy. The Colonel was President Woodrow Wilson's advisor, particularly in the area of foreign affairs. Paris Peace Conference.
• King George V of the United Kingdom suffered from pleurisy in his later life.
• Carson McCullers, author of The Heart is a Lonely Hunter, was diagnosed with influenza and pleurisy in 1944.^[44]
• Ringo Starr, former Beatles drummer, had chronic-pleurisy at age 13 in 1953.^[45]
• Basil Sydney, the British actor died of the condition in 1968.
• LeBron James, an American professional basketball player, was diagnosed with pleurisy after being admitted to the Cleveland Clinic in October 2005 with complaints about chest pain during practice.^[46]
• Ken Griffey, Jr., an American professional baseball player, complained of soreness in the chest and after a chest x-ray was diagnosed with pleurisy in April, 2007.^[47]
• Shin Dongho, former U-KISS member, was diagnosed with pleurisy. He experienced pains in his chest on a way to a scheduled event and was taken to the emergency room where they ran tests. Was diagnosed mid-October 2012.
• Richard Bull, Esquire, attorney-at-law and unofficial mayor of La Jolla, CA (and a Bishop's School graduate) was diagnosed with pleurisy. He experienced pains in his left flank during a late night conference call and was taken to the emergency room the next day where they ran tests. During such late night conference call, a fellow colleague announced that he would not perform CPR if it became necessary. Was diagnosed early July 2014.