A 25 Year Old Female Presents With Chest Pain On Deep Breathing And Coughing

A 25 year old female comes to her primary care physician because she has been unwell for the past few days with fever, cough and difficulty breathing. She complains of having a sharp localized chest pain when she takes a deep breath or coughs. On Examination she had a fever of 102 F and had a fast breathing. On auscultation a pleural friction rub was heard.
Chest X ray shows few infiltrates but was otherwise normal:


                                                                                                                                                                                                                                                               What is the cause Of her Chest Pain?
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The patient is most likely having pleuritc chest pain that is caused by inflammation of the pleura secondary to viral or bacterial lung infection.

Case Discussion:

 PLEURISY / PLEURITIC CHEST PAIN

Pleurisy is defined as an inflammation of the pleura (the lining that surrounds the lungs). This condition can cause sharp pain when breathing and is known as pleuritic chest pain.

Causes:

• ·         Viral infections (coxsackievirus, RSV, CMV, adenovirus, EBV, parainfluenza, influenza) is the most common cause of pleurisy.
• ·         Bacterial lung infection due to pneumonia or Tuberculosis.
• ·         Chest injuries
• ·         Autoimmune diseases like SLE, RA,
• ·         Malignancy
• ·         Pulmonary embolism
• ·         Drug reactions
• ·         Liver diseases.

Clinical Features: Depending upon the underlying cause of pleurisy patients may present with a variety of clinical signs and symptoms. These include:

• ·         High grade fever with chills
• ·         Cough (may be productive)
• ·         Difficulty breathing
• ·         Rapid heart rate.
• ·         Pleuritic chest pain which is sharp and localized and tends to be intensified by coughing, sneezing, deep inspiration or chest movements.
• ·         Pleural rub. ( a rough scratchy sound heard on auscultation of chest)

Diagnosis: Along with history and clinical findings following investigation may help in diagnosis:

• ·         Chest X ray: may show infiltrates or opacities (in case of pneumonia), effusions (in pulmonary embolism and malignancy), lack of lung markings (in pneumothorax), rib fractures (in case of trauma)
• ·         ECG : is done to exclude cardiac causes
• ·         CBC: increased neutrophils indicates infections like pneumonia.

Management:

1.       NSAIDs are the initial treatment to reduce inflammation and pain.

2.       If the underlying cause is pneumonia Antibiotics are needed.

3.       Methotrexate sometimes needed if underlying cause is an autoimmune disorder.