What is pleurisy?
Pleurisy is an inflammation of the membrane called pleura that covers the lungs. The main symptom is sharp pain in the chest aggravated by breathing and coughing. Pleurisy can be caused by mild conditions, such as flu, or life-threatening conditions, such as pulmonary embolism or cancer.
What is the pleura?
The pleura is a membrane with 2 layers: the inner layer (visceral pleura) covers the lungs and the outer layer (parietal pleura) lines the inner surface of the chest cavity. Between the two layers, there is a thin space called pleural cavity, which contains some fluid, which allows smooth sliding of the two membranes over each other during breathing.
The bottom surface of the pleura sits on the diaphragm–the main breathing muscle that separates the chest and abdominal cavity.
Causes of pneumonia in a rough order from most to least common :
- Viral infection, such as flu, or an infection with respiratory syncytial virus (RSV), mumps, cytomegalovirus (CMV), adenovirus, and Epstein-Barr virus (EBV–in Lyme disease)
- Inflammatory diseases: systemic lupus erythematosus (SLE), rheumatoid arthritis, inflammatory bowel disease (Crohn’s disease, ulcerative colitis), Sjögren’s syndrome
- Pericarditis–an inflammation of the heart sac
- Medications: acyclovir, amiodarone, bromocriptine, chemotherapeutics, clozapine, dantrolene, D-penicllamine, isotreonin, itroconazole, mesalamine, methysergide, nitrofurantion, simvastatin, valproic acid 
- Chest injury
- Bacterial pneumonia
- Parasitic infection, such as amebiasis and paragonimiasis
- Fungal infection
- Pulmonary embolism–a blood clot in the pulmonary artery, most commonly in individuals with deep vein thrombosis
- Heart attack (Dressler’s syndrome after a myocardial infarction)
- Chronic kidney failure (uremia)
- Lung cancer
- Asbestosis – after occupational or environmental exposure to asbestos
- Pneumothorax – a spontaneous or traumatic collapse of a lung wing
- Sickle cell disease – a common cause of pleurisy in children
- Familial Mediterranean fever – a genetic disease with recurrent pleurisy
Symptoms and Signs
The main symptom in pleurisy is “pleuritic pain,” which is a localized, sharp and stabbing pain in the side of the chest, upper or middle back or upper abdomen triggered by deep inspiration, talking, coughing, sneezing or moving, such as lifting the arms above the head, bending or twisting the upper body. The pain can be mild or severe, sudden or chronic.
Chest wall tenderness. In acute pleurisy, such as in pneumonia, the overlying chest wall muscles are rarely and in chronic pleurisy, such as in rheumatoid arthritis, commonly tender to touch .
More common causes of chest wall tenderness are myofascial pain and muscle strain.
It is an inflammation of the outer layer of pleura (parietal pleura) that causes pain . The phrenic nerve that enables sensations in the pleura also enables sensations in the shoulder tip, so pleurisy can cause referred pain in the shoulder blade.
Symptoms associated with the underlying causes are described in the Chart 1 below.
Pleurisy causes sharp grating sounds during breathing when a doctor listens your lung with the stethoscope. Other signs, such as decreased breathing sounds or crackles suggest an underlying disease, such as pneumonia.
A doctor can often make a diagnosis of pleurisy solely on the basis of your symptoms and listening your lungs with the stethoscope.
An X-ray is usually the first imaging investigation, which may reveal an underlying condition, such as pneumonia, pericarditis or pneumothorax .
Additional investigations may be needed to find a cause of pleurisy:
- Thoracocentesis – aspiration of fluid from the pleural cavity with a needle
- Pleural biopsy. When a doctor suspects tuberculosis or cancer, he or she can take a small piece of the pleural tissue with a needle and send it to a histological investigation (under the microscope)
- Thoracoscopy–an endoscopic investigation of the chest cavity using a flexible tube with a light and camera on the end
Chart 1. Pleurisy Differential Diagnosis
|Flu||High fever, muscle pain||/|
|Bacterial pneumonia||High fever, shortness of breath, fatigue||X-ray: lung shadows|
|Lupus, rheumatoid arthritis||Symmetrical swelling of the joints in the hands||Blood: antibodies|
|Coronary heart disease (angina pectoris, heart attack)||Severe, squeezing pain behind breastbone and shoulder blades||Typical ECG result|
|Pericarditis||Pain behind breastbone worse when lying||X-ray: a shadow around the heart|
|Tuberculosis||Night sweats, coughing up blood||X-ray: lung shadow; sputum culture|
|Lung cancer||Dry cough or coughing up blood||X-ray: a rounded shadow in the lung|
|Pneumothorax||Sudden, sharp chest pain||X-ray: a collapsed lung wing|
|Malignant mesothelioma||Chronic cough||X-ray, CT or MRI: a lung shadow|
Chart 1 source: American Family Physician  , Emedicine 
Other conditions that can cause chest pain aggravated by breathing:
- Strain of the chest wall muscles (localized tenderness)
- Trapped wind (pain in the upper left or right abdomen, bloating)
- Serratus anterior muscle pain syndrome (pain below the armpit on one or both sides)
- Costochondritis (tenderness near the sternum, usually on the left side)
- Shingles or herpes zoster (nerve pain with or without rash; very tender to touch)
- Enlarged spleen (a palpable lump on the left side of the abdomen) or other painful splenic disorder
- Rib fracture (severe tenderness, rib deformity)
Viral pleurisy usually heals on its own.
Treatment depends on the underlying cause and can include :
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or indomethacin, to reduce the pain
- Antibiotics for bacterial pneumonia or tuberculosis
- Steroids for systemic lupus erythematosus
- Aspiration of the pus or blood from the pleural cavity
- Pleural effusion – collection of fluid in the pleural cavity
- Empyema – collection of pus in the pleural cavity (can cause high fever)
- Adhesions – scar tissue that glues the two layers of pleura and can cause occasional mild but sharp pains
- Pneumothorax–a rupture of pleura resulting in a collapse of a lung wing (usually only on one side at the time)
Frequently Asked Questions
Recovery time – how long does pleurisy last?
Recovery time for pleurisy depends on the underlying cause and the treatment success: in flu, it can last for few days and in systemic lupus erythematosus for several months.
Is pleurisy contagious?
Pleurisy by itself is not contagious but you can catch microbes from a person who has pleurisy associated with flu, viral or bacterial pneumonia.
Can smoking cause pleurisy?
There seems to be no evidence about association between smoking and pleurisy. Smoking can cause chronic bronchitis or lung cancer, though.
Are there any home remedies to treat pleurisy?
There is insufficient evidence that home remedies, such as turmeric, pleurisy root  or other herbs or teas help in pleurisy.
- Kass SM et al, 2007, Pleurisy American Family Physician
- Confer J et al, 2012, Pleurisy — symptom or condition Medscape
- Pleural effusion differential diagnosis Emedicine
- Laënnec RTH, 1834 A treatise on the disease of the chest, tr,. by J. Forbes, p.413
- Pleurisy root WebMD