Conditions
Pleurisy or pleuritis, is an inflammation of the pleura (the membranes lining the lung surface and inside the chest wall), usually with accompanying fluid formation.
Symptoms
The predominant symptom of pleurisy is painful breathing: the pain is stabbing in nature, worse with inspiration and may limit movement on the affected side of the chest. The resulting disturbance of breathing can cause shortness of breath or dizziness. Unless pleuritis is also present, pleurisy with fluid production (effusion) usually causes shortness of breath and vague chest discomfort rather than pleuritic, stabbing pain. Pleurisy itself can cause non-specific symptoms like fever, cough and weight loss. However, the underlying cause of the pleurisy may have symptoms of its own.
Causes and associated conditions
Mechanical Collapse of a lung due to a spontaneous pneumothorax causes sudden pleuritic pain. A large pneumothorax can cause respiratory distress. Those most at risk are tall, thin, young men who smoke, and have no underlying lung disease. The recurrence rate is high. In some patients, the pneumothorax is a complication of underlying disease such as chronic obstructive lung disease. A form called tension pneumothorax is rare, but potentially life-threatening. A chest wall injury causes tissue to act as a flap valve, forcing into and then trapping more air in the chest with each breath; this progressively squashes the lung and can eventually compress the other (healthy) lung as well. The heart and vital structures are also affected. Immediate emergency decompression is needed. Pulmonary embolus is a most important cause and must always be excluded, because of a potentially serious or life-threatening outcome. Urgent treatment is needed for pulmonary embolus. Patients at risk are those in hyper-coagulable states due to disease, medication, or recent prolonged immobility (bed-rest, air-travel, surgery trauma) or immediately after giving birth. Inflammatory/Infective A common cause in young people is viral pleurisy. Tuberculosis is a common cause. Other causes Automimmune conditions like rheumatoid arthritis and systemic lupus can cause pleuritc pain. Some drugs, notably procainamide, hydralazine and isoniazid are also implicated, causing a lupus-like syndrome. Malignant disease Primary malignancies of the pleura are rare (e.g. malignant mesothelioma) Secondary spread to the pleura is much more common and often seen in advanced breast cancer, where large recurrent effusions result.
Diagnosis
The diagnosis of pleurisy is mainly clinical. The nature of the pain and associated symptoms is typical. A characteristic friction rub may be heard through the stethoscope - this is the sound of inflamed pleural surfaces rubbing against each other during breathing. If an effusion is present, one side of the chest will move less than the other and will sound dull when tapped. Diminished breathing sounds will suggest a possible pneumothorax. Evidence of a deep vein thrombosis or history of recent surgery will make pulmonary embolus more likely. Chest X-ray will demonstrate a pneumothorax or effusion and may show other related conditions like an unsuspected lung cancer, or malignant secondaries. Other tests - blood tests or skin tests - may be done to confirm underlying disease, such as tuberculosis. However, the presence of an underlying associated condition may be suggestive, but does not exclude another pathology causing an effusion. In this case, some of the fluid is removed for analysis - a procedure called paracentesis or thoracocentesis. A risk of this procedure is that the needle used to drain the fluid may damage the lung, causing it to collapse. If a large effusion is present, this may need formal drainage to allow the lung to re-expand properly.
Treatment
Definitive treatment will depend on the cause. Underlying infective or auto-immune diseases are treated with appropriate medications. If the pleurisy is due to secondary malignant spread, it is often too late to treat the primary tumour. In these patients, effective pain management is mandatory. Large malignant effusions can be drained, but quickly recur. Talc pleurodesis is a process of insufflating talc into the pleural space immediately after draining a malignant effusion. This causes such an intense inflammation of the pleura that the surfaces stick to each other, thereby obliterating the space, leaving nowhere for the effusion to re-form. It is a very painful procedure, has a high failure rate and is thus not routinely done.
Outcome
Spontaneous pneumothorax has a high recurrence rate, as do conditions due to underlying lung disease. Prompt and adequate treatment of pulmonary embolus may have a good outcome. Pleurisy associated with malignancy has a poor outcome. Dr AG Hall