Pleurisy

Pleurisy is an inflammation of the pleura. The pleura is a large, thin membrane that wraps around the outside of the lungs and lines the inside of the chest cavity. Between the layer of the pleura that wraps around the lungs and the layer that lines the chest cavity is a very thin space. This is called the pleural space. The pleural space is normally filled with a small amount of fluid. The fluid helps the two layers of the pleura glide smoothly past each other as the lungs breathe air in and out.

Pleurisy occurs when the two layers of the pleura become inflamed. Inflammation is a protective and healing process characterized by swelling, redness, heat, and pain. The inflamed pleural layers rub against each other every time the lungs expand to breathe in air. This can cause sharp pain with breathing. Infections like pneumonia are the most common cause of pleurisy.

Front view of thorax, showing the relations of the pleura and lungs to the chest wall. Pleura in blue; lungs in purple. Source: Gray's Anatomy, 1918.

Other Names

• Pleuritis

Symptoms

The main symptom of pleurisy is a sharp or stabbing pain in the chest that gets worse with deep breathing, coughing or sneezing. The pain may stay in one place, or it may spread to the shoulder or back. Sometimes it becomes a fairly constant dull ache.

Depending on what's causing the pleurisy, one may have other symptoms:

• Shortness of breath
• Cough
• Fever and chills
• Rapid, shallow breathing
• Unexplained weight loss
• Sore throat followed by pain and swelling in the joints

Causes

Viral infection is the most common cause of pleurisy. However, many different conditions can cause pleurisy:

• Bacterial infections like pneumonia and tuberculosis
• Autoimmune disorders like systemic lupus erythematosus and rheumatoid arthritis
• Lung cancer, including lymphoma
• Other lung diseases like sarcoidosis, asbestosis, lymphangioleiomyomatosis, and mesothelioma
• Pulmonary embolism, a blood clot in the blood vessels that go into the lungs
• Inflammatory bowel disease
• Familial Mediterranean fever, an inherited condition that often causes fever and swelling in the abdomen or lung
• Infection from a fungus or parasite
• Heart surgery, especially coronary artery bypass grafting
• Chest injuries
• Reaction to certain medicines that can cause a condition similar to systemic lupus erythematosus. These medicines include procainamide (Pronestyl), hydralazine (Apresoline), and isoniazid.

Some cases of pleurisy are idiopathic, meaning the cause cannot be determined.

Diagnosis

A diagnosis of pleurisy or another pleural condition is based on medical histories, physical exams, and diagnostic tests. The goals are to rule out other sources of the symptoms and to find the cause of the pleurisy so the underlying disorder can be treated.

Medical history

Doctors take detailed medical histories to help make a diagnosis. Below are some important aspects of the pain:

• What it feels like
• Where it's located and whether it can be felt in the arms, jaw, or shoulder
• When it started and for how long
• What makes it better or worse
• Whether it goes away and then comes back

A doctor also takes into account any other symptoms, such as shortness of breath, cough, or palpitations.

The doctor also considers a history of the following conditions:

• Heart disease
• Smoking
• Travel to places where there might have been exposure to tuberculosis
• A job with exposure to asbestos
• Having taken nitrofurantoin (Macrobid) or amiodarone( Cordarone) or a medicine that can cause a condition that's similar to systemic lupus erythematosus (an autoimmune disorder)

Physical exam

A doctor uses a stethoscope to listen to the breathing. This detects any unusual sounds in the lungs. A person with pleurisy will 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, and it is a good sign of pleurisy.

Diagnostic tests

Depending on the results of the physical exam, 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 what's causing the pleurisy –for example, pneumonia, a fractured rib, or a lung tumor.

Sometimes an x-ray is taken while lying on the painful side. This may show fluid that did not appear on the standard x-ray taken while standing.

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.

Ultrasound

Ultrasonography uses sound waves to create pictures of the lungs. It may show where fluid is located in the chest. It also can show some tumors.

Magnetic resonance imaging (MRI)

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

Blood tests

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

Arterial blood gas

In this test, a small amount of blood is taken from an artery 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

Once the presence and location of fluid is confirmed, a sample of fluid can be removed for testing. The procedure to remove fluid in the chest is called thoracentesis. The doctor inserts a small needle or a thin, hollow, plastic tube through the ribs in the back of the chest into the chest wall and draws fluid out of the chest.

Thoracentesis usually doesn't take long. Most of the time, it 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 doesn't cause serious complications. Generally, a chest x-ray is done after the procedure to evaluate the lungs. Possible complications of thoracentesis include the following:

• 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.
• Pain.
• 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.
• Rarely, liver or spleen injury.

The fluid removed by thoracentesis is examined under a microscope. It is evaluated for the presence of chemicals and for its color, and texture. The clearness of the fluid 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.

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. remove a sample of the pleura through a small cut in the chest wall. This is called an open pleural biopsy. It's usually done if the sample from the needle biopsy is too small for an accurate diagnosis.

Treatment

Treatment has several goals:

• Remove the fluid, air, or blood from the pleural space
• Relieve symptoms
• Treat the underlying condition

Procedures

If large amounts of fluid, air, or blood are not removed from the pleural space, they may put pressure on the lung and cause it 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 liters) 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 don't drain out, surgery may be necessary.

Medications

A couple of medications are used to relieve pleurisy symptoms:

• Acetaminophen (Tylenol) or anti-inflammatory agents, such as ibuprofen (Advil, Motrin), to control pain and decrease inflammation. Only indomethacin (Indocin) has been studied with respect to relief of pleurisy. ^[1]
• 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 before they are used routinely.

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 plenty of 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 antitumor 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.

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.^[2][3] The extract is thought to inhibit the same enzyme, cyclooxygenase-2 (COX-2), as the non-steroidal anti-inflammatory drugs.^[3] Similarly, an extract from the roots of the Brazilian Petiveria alliacea plant reduced inflammation in a rat model of pleurisy.^[4] 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.^[5]

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.

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 in which not enough blood and oxygen reach important organs in the body.

Clinical Trials

Clinical Trials involving tuberculous pleurisy are currently recruiting. Information is available here

History

Dr. John Tennent, a Virginia botanist, wrote the first home medicine manual in America in 1736. It was titled "Every Man His Own Doctor; or, The Poor Planter’s Physician". Dr. Tennant described a treatment for pleurisy:

"A Common Consequence of a violent Cough is a Pleurisy; which discovers it self by a brisk Fever, and sharp Pain, pretty low in one of the Sides, shooting now and then into the Breast, and sometimes quite back into the Shoulder-Blades. It is uneasy every Time the Patient draws his Breath, and more so when he coughs; which is generally the Case in this Disease. The Moment any Person finds these Tokens upon him, he must, without Loss of Time, take away 10 Ounces of Blood, and repeat the same 3 or 4 Days successively, if the Pain go not away before. On the Third Day, he may vomit with 80 Grains of Indian Physick (Virginian Ipecoacanna,) and every Night, drink 7 Spoonfuls of Pennyroyal Water, or the Decoction of it, moderately sweeten'd. In the mean Time, let him, every Three Hours, take Half a Spoonful of Honey and Linseed Oyl mixt together. He should also strew Indian Pepper, upon Pennyroyal Plaister, and apply it very hot to the Place where the Pain lies, and be sure to keep himself warm, and abstain from cold Water: Tho' if the Distemper should prove obstinate, you must apply a Blister to his Neck, and one to each Arm, on the fleshy Part above the Elbow. The Patient's Diet should be light, and cooling; and his constant Drink, either Linseed, or Balm Tea, a little sweeten'd. The best Way to prevent this Distemper, will be, to bleed in the Beginning of any great Hoarseness, or Cough, and also to forebear swilling great Quantities of Water, or Small Beer, in ordinary Life." ^[6]

Dr. Tennent was introduced to Seneca snakeroot by the Seneca Indians. The herb was previously used for snake bites. Since Dr. Tennent felt the symptoms of snake bite and pleurisy were similar, he used Seneca effectively to treat pleurisy. He brought the herb to London in 1837, where it was well received, marketed, and used for a variety of conditions in the latter half of the 1700s. It is still used as an alternative medicine for cough, especially in Europe. ^[7]

Pleurisy root

Pleurisy root, or butterfly weed, was so named because it was used by Native Americans to treat pleurisy. The root was said to encourage coughing by thinning the mucous in the lungs. Pleurisy root is not used much today because more effective medicines are available.

References

1. ↑ Klein RC. Effects of indomethacin on pleural pain. South Med J. 1984 Oct;77(10):1253-4. Abstract.
2. ↑ Peters RR, Saleh TF, Lora M, et al. Anti-inflammatory effects of the products from Wilbrandia ebracteata on carrageenan-induced pleurisy in mice. Life Sci. 1999;64(26):2429-37. Abstract.
3. ↑ ^{3.0 3.1} Siqueira JM Jr, Peters RR, Gazola AC, et al. Anti-inflammatory effects of a triterpenoid isolated from Wilbrandia ebracteata Cogn. Life Sci. 2007 Mar 20;80(15):1382-7. Abstract.
4. ↑ Lopes-Martins RA, Pegoraro DH, Woisky R, Penna SC, Sertié JA. The anti-inflammatory and analgesic effects of a crude extract of Petiveria alliacea L. (Phytolaccaceae). Phytomedicine. 2002 Apr;9(3):245-8. Abstract.
5. ↑ Goulart S, Moritz MI, Lang KL, Liz R, Schenkel EP, Fröde TS. Anti-inflammatory evaluation of Solidago chilensis Meyen in a murine model of pleurisy. J Ethnopharmacol. 2007 Sep 5;113(2):346-53. Epub 2007 Jul 7. Abstract.
6. ↑ Armory Hill Living History Association. Every Man His Own Doctor: or, The Poor Planter's Physician
7. ↑ HerbalProject.com: Hypericum perforatum

External Links

American Lung Association