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Pleurisy, also known as Pleuritis, is the inflammation of the parietal pleura causing sudden pain during inhalation or exhalation. However, the symptom can vary from severe pain, to asymptomatic. The pain may worsen while coughing, taking deep breath, sneezing, and body bending and twisting. The description of pain may vary as well including dull sharp, burning, catching and stabbing (Brims et al, 2010).
The underlying cause of pleurisy can be cardiac causes, gastrointestinal causes, oncologic causes, hematologic causes, iatrogenic causes (acquired), infectious causes (bacterial, or viral), autoimmune causes, pulmonary causes, and renal causes. All the causes will eventual lead inflammation in the pleural cavity in pleurisy (Reamy et al., 2017).
The key for diagnosis is to exclude the possible most life-threatening causes first before diagnosing other non-life-threatening causes. The most common life-threatening causes of pleurisy is pulmonary embolism (Reamy et al., 2017). According to Reamy et al., 5% to 21% of patients with pleurisy were reported with pulmonary embolism as the cause of the condition. However, additional test should be made to validate the diagnosis by excluding other possible causes. The test includes physical examination, auscultation, D-dimmer assays, ventilation -perfusion scan or CT (computed tomography) angiograph (Reamy et al., 2017). In physical examination, one of the indications for pulmonary embolism is the unilateral swelling in the extremity (Reamy et al., 2017). Acute onset dyspnea may indicate pulmonary embolism is the cause of pleurisy (Brenner et al., 2014). Auscultation on the heart can lead to two possible differential diagnosis, aortic dissection and myocardial infarction. Presence of third heart sound may indicate patient is having a heart attack. Aortic murmur or cardiac tamponade (accumulation of fluid in the pericardial sac) may suggest pneumothorax (Traumatic Pericardial Tamponade – Emergency Management; Reamy et al, 2017 ). Pneumothorax is the collapse of the lung. The accumulation of fluid in the pleural cavity (pleural effusion) will might lead to dullness on the lung percussion (Saguil et al., 2014). D-dimmer is a diagnostic test for the presence of biological marker for aortic dissection (Diercks DB et al., 2015). Ventilation-perfusion scan is a diagnostic tool for pulmonary embolism (Anderson et al, 2007). In addition, although lacking direct evidence, CT angiography may be better test for ruling out Pulmonary Embolism than Ventilation-perfusion test. The meta-analysis reveal that helical CT has higher sensitivity (86.0% with 95% confidence interval) than V/P scanning (39.0% with confidence level of 95%) (Hayashino et al, 2005). The specificity of detecting PE are 93.7% and 98.3% for helical CT and V/P scan respectively (Hayashino et al, 2005).
Differential diagnosed is necessary to be made to exclude other serious causes that could cause pleurisy: myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax. The patients’ history, physical exam, electrocardiograph (ECG), troponin assays and chest radiograph are the tests for differential causes mentioned above (Reamy et al., 2017). ECG is the most commonly used diagnostic tool for detection of heart abnormality. In this case, ECG was used to detect STEMI (ST-elevation myocardial infarction) (Ibanez et al., 2018). Troponin assays are used to rule out Acute Coronary Syndrome (ACS) (Hoeller et al., 2013). Depending on the level of the troponin level, physician can estimate the time of the onset from the initial acute myocardial infarction (Hoeller et al., 2013). In addition, presence of nausea, sweat, and palpitation with pleurisy indicates the cause is cardiac problem rather pleuritic cause. In addition, older patients have higher chances of malignant pleural effusion or coronary artery disease while having pleurisy as a symptom (Reamy et al., 2017). Chest radiograph can detect presence of pneumonia and pneumothorax. Air bronchogram sign is a good indication of pneumonia. Alveoli are not normally seen in X-ray. When the fluid accumulates in the alveoli, the alveoli become visible to X-ray (Kahn et al., 2009). The deep sulcus sign is a deep one-sided angle between the lung and the diagram. The deep sulcus sign indicates pneumothorax due to the air space accumulated the thoracic cavity (Algın et al., 2011).
In general, progressive pain over the hours, days or week suggest the cause is not severe (Reamy et al., 2017). During physical examination, difference in pain and location of pain can indicate different causes for pleurisy. For example, pericarditis usually results in worsen pain when laying supine and lessen pain when standing upright. Myocardial infarction highly correlate with radiating chest pain to the shoulder or arms. In aortic dissection, the tearing pain radiates to the back with highest intensity. If the pain is on the shoulder or the chest, this can indicate pneumothorax (Reamy et al., 2017). During general physical exam, hypotension and tachycardia with pleurisy may indicate the cause of disease as pulmonary embolism, or myocardial infarction. Tracheal deviation from the x-ray suggests increase in intrathoracic pressure the in the chest cavity, which means that pneumothorax might be present. In addition, the sensation of pain can be received from local pain receptor or fast-conducting-A-delta receptor, which why there are difference in sensation of pain. Dull pain can be received from the local pain receptors from the somatic nerves from the parietal pleura. In the hemidiaphragm, the intercostal nerves transmit the localized pain. The referred pain is localized to the cutaneous area innerved by the intercostal nerve. In central diaphragm, the pain transmitted by phrenic nerve. The referred pain is localized at one-sided neck or shoulder pain (Lee et al., 2012).
Although pulmonary embolism is the most common cause for pleurisy in life threatening situation, 90 percent of patients with pneumothorax also have pleurisy. Fifty percent of patients with systemic lupus erythematosus (SLE) have pleurisy. Fifty percent of patients with community-acquired pneumonia have pleurisy (Brims et al., 2010). While obtaining past medical history, there is increase risks of having prior disease. Viral infection could cause pleurisy including: Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus (Reamy et al., 2017). Other prior diseases that can increase the risk of pleurisy include prior pericarditis, malignancy, pulmonary embolism, venous thromboembolism, exposure to tuberculosis, and sickle cell disease (Reamy et al., 2017).
The treatment for pleurisy is to treat the primary cause. For non-emergency management, nonsteroidal anti-inflammatory drugs should be the first choice for pain control. However, if the patient has refractory disease, NSAID should not be used. Instead, acetaminophen, corticosteroid or opioid should be used (Reamy et al., 2017). Because the most life-threatening common cause of pleurisy is pulmonary embolism. The immediate treatment should be discussed for pulmonary embolism. The initial recommended medication includes 15mg rivaroxaban twice a day for three weeks and 10mg apixaban twice daily for 1 week. The two drugs mentioned above are direct anticoagulant (Cardiology, 2015). The grading system for this treatment is grade 1, and level B according to European Society of Cardiology. Grade 1 means that there is a consensus that the treatment is beneficial for the condition (highest possible grade). Level B indicates the source of the data is from an either large nonrandomized study or single randomized trial (second highest grading) (Cardiology, 2015). In addition, vitamin K oral intake was recommended for the first three months of taking the anticoagulant (Apixaban and rivaroxaban) as an antagonist to prevent excessive bleeding. Five to ten days after the initial treatment of direct oral anticoagulant, indirect anticoagulant treatment is recommended, which included drugs like dabigatran 150 mg twice daily, and edoxaban 60 mg once daily (Cardiology, 2015).
In summary, the sequence of diagnostic tests usually goes as follow in order to rule out life threatening causes of pleurisy: first, history and physical exam on the patients is taken. Medications such as amiodarone etc. can cause pleurisy (Sara et al., 2007; Reamy et al., 2017). Second, chest x-ray was performed. Additional, lung ultrasound and high-resolution CT can be performed to clarify diagnosis (Brims et al., 2010). Interestingly, in Volpicelli et al’s study, lung ultrasound is a better predictor for raio-occult pleural-pulmonary lesions than blood test of D-dimmer and white blood cells. The prediction correlation was presented as area under the curve (AUC). The higher the AUC is, the better the prediction for radio-occult pleural-pulmonary lesion. The AUC for lung ultrasound is 0.967. The AUC for d-dimmer and white blood cell count are 0.815 and 0.778 respectively (Volpicelli et al., 2012). Volpicelli even mentioned that “None of the other routine tests (lung utlrasound) considered or a combination between them (d-dimmer and white blood cell count) better predicted the final diagnosis” (Volpicelli et al., 2012).
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