Pleuritis

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1- Introduction

2- Pathophysiological Overview

3- Symptoms

4- Treatment

Introduction

Pleuritis, also known as pleurisy, is an inflammation of the pleura, the thin membranes that line the chest cavity and surround the lungs. This condition causes sharp chest pain that worsens with breathing, coughing, or sneezing. The pain occurs because the inflamed pleural layers rub against each other during respiration. Pleuritis can result from various causes, including infections (like viral or bacterial pneumonia), autoimmune diseases (such as lupus), pulmonary embolism, or trauma. Treatment typically focuses on addressing the underlying cause and relieving pain and inflammation.

Pathophysiological Overview

Inflammatory Response:
- Trigger: The inflammation can be triggered by infections (bacterial, viral, or fungal), autoimmune diseases (such as lupus or rheumatoid arthritis), pulmonary embolism, malignancies, or chest trauma.
- Immune Response: When the pleura are exposed to these triggers, the body’s immune response is activated, leading to the release of inflammatory mediators like cytokines and prostaglandins.
Pleural Membrane Changes:
- Thickening and Swelling: The inflammation causes the pleural membranes to thicken and become swollen, leading to reduced lubrication between the layers.
- Decreased Pleural Fluid: Normally, the pleural cavity contains a small amount of lubricating fluid that allows the lungs to move smoothly during breathing. In pleuritis, the inflamed pleura may produce less fluid, or the fluid may become more viscous, increasing friction.
Friction and Pain:
- Pleural Rub: The inflamed pleural layers rub against each other during respiration, causing a characteristic pleural rub sound, which can be heard during a physical exam.
- Sharp Chest Pain: The friction between the layers leads to sharp, stabbing chest pain that is aggravated by breathing, coughing, or sneezing. The pain occurs because the pleura have a rich supply of nerve endings.
Potential Complications:
- Pleural Effusion: In some cases, excess fluid may accumulate in the pleural space, leading to a pleural effusion. This can reduce pain but may cause breathing difficulties due to the compression of the lung.
- Fibrosis and Adhesions: Chronic or severe inflammation can result in fibrosis (thickening and scarring) of the pleura, leading to restricted lung movement and ongoing pain.
Resolution or Progression:
- Resolution: With appropriate treatment, such as antibiotics for infections or anti-inflammatory medications for autoimmune causes, the inflammation can resolve, and the pleural layers return to normal.
- Chronic Pleuritis: If the underlying cause is not addressed or is chronic, pleuritis can persist, leading to ongoing symptoms and potential complications like pleural thickening or effusion.

Symptoms

Sharp Chest Pain: Typically the most prominent symptom, this pain is usually localized to one side of the chest and worsens with deep breathing, coughing, sneezing, or laughing.
Pain with Breathing: The pain intensifies with inspiration (breathing in) due to the movement of the inflamed pleura.
Shortness of Breath: Breathing may become shallow or rapid to minimize the pain, leading to feelings of breathlessness.
Cough: A dry cough is common and may aggravate the chest pain.
Pleural Rub: A grating or rubbing sound heard with a stethoscope, caused by the inflamed pleura rubbing against each other during breathing.
Fever and Chills: If the pleuritis is caused by an infection, there may be associated fever, chills, and general malaise.
Radiating Pain: Pain may radiate to the shoulders or back if the inflammation affects certain areas of the pleura.
Muscle Pain: Pain in the shoulder or upper abdomen due to the irritation of the nerves that supply the pleura.
Fatigue: General tiredness or fatigue may accompany pleuritis, especially if it is part of a systemic condition like an infection or autoimmune disease.
Decreased Breath Sounds: In cases where pleuritis is accompanied by pleural effusion, breath sounds may be diminished over the affected area of the lung.

Treatment

1. Treating the Underlying Cause

Antibiotics: If pleuritis is caused by a bacterial infection, antibiotics are prescribed to eliminate the infection.
Antiviral Medications: For viral infections, antiviral medications may be used, although many viral causes resolve on their own with supportive care.
Antifungal Medications: For pleuritis caused by a fungal infection, antifungal drugs are necessary.
Treatment of Autoimmune Disorders: If pleuritis is due to an autoimmune condition like lupus or rheumatoid arthritis, treatment may include corticosteroids, immunosuppressants, or disease-modifying antirheumatic drugs (DMARDs).

2. Symptom Relief

Pain Relief:
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Medications like ibuprofen or naproxen are commonly used to reduce inflammation and relieve pain.
- Acetaminophen: May be used to manage pain if NSAIDs are contraindicated.
- Stronger Pain Relievers: In cases of severe pain, stronger pain medications or opioids may be prescribed for short-term use.
Cough Suppressants: If a persistent cough is worsening the pain, a cough suppressant may be recommended.
Heat Therapy: Applying a warm compress to the chest may help soothe pain.

3. Managing Pleural Effusion (If Present)

Thoracentesis: If fluid has accumulated in the pleural space (pleural effusion), a procedure called thoracentesis may be performed to remove the excess fluid and relieve pressure on the lungs.
Chest Tube: In cases of large or recurrent pleural effusions, a chest tube may be inserted to continuously drain fluid.

4. Rest and Recovery

Rest: Ensuring adequate rest can help the body recover, especially in cases where pleuritis is part of a systemic infection or illness.
Avoiding Strain: Patients are advised to avoid activities that exacerbate pain, such as heavy lifting or vigorous exercise.