Pleurisy: Symptoms, Types, Causes and Treatment

Pleurisy, also known as pleuritis, is a condition where the pleura—the thin, double-layered membrane surrounding the lungs—becomes inflamed. This inflammation can cause sharp chest pain and other symptoms, and it may be triggered by a variety of underlying health conditions. Understanding pleurisy is essential, as its symptoms can sometimes mimic those of other serious diseases. This article explores the symptoms, types, causes, and treatment options for pleurisy, drawing on recent research and clinical insights.

Symptoms of Pleurisy

Pleurisy can present in a variety of ways, but it is most famously associated with sharp chest pain that worsens with breathing. However, the symptom profile can be broader and sometimes even subtle, making diagnosis a challenge.

Symptom	Description	Frequency/Context	Source(s)
Chest pain	Sharp, stabbing, worsened by deep breaths	Most common, classic symptom	1, 6
Shortness of breath	Difficulty breathing, especially on exertion	May accompany or follow pain	1, 6
Fever	Elevated temperature, often with infection	Seen in infectious pleurisy	1, 4
Cough	Dry or productive, variable presence	In some infectious cases	1, 4
Asymptomatic	No symptoms, found incidentally on imaging	Especially in asbestos-related	2
Hypoxemia	Low blood oxygen levels	Severe cases, e.g., viral pleurisy	1

Table 1: Key Symptoms

Classic Clinical Features

The hallmark of pleurisy is pleuritic chest pain—a sharp, stabbing pain that worsens with deep breaths, coughing, or sneezing. This pain is caused by the inflamed pleural layers rubbing against each other during respiratory movements. In some cases, the pain may be localized to one side of the chest and can be intense enough to restrict breathing movements 1.

Additional and Atypical Symptoms

• Shortness of breath: This may be due to the pain itself or to a buildup of fluid (pleural effusion) that restricts lung expansion 1.
• Fever and cough: These are more likely in infectious forms of pleurisy, such as those caused by pneumonia or tuberculosis 4.
• Hypoxemia: In severe cases, oxygen levels in the blood may drop, requiring supplemental oxygen 1.
• Asymptomatic cases: Some forms of pleurisy, especially those related to asbestos exposure, can be entirely symptom-free and only detected via imaging 2.

Symptom Variation by Cause

Symptoms can vary significantly depending on the underlying cause:

• Infections (bacterial, viral, TB): Typically present with pain, cough, and fever 1, 4.
• Systemic diseases (e.g., rheumatoid arthritis, lupus): May have subtle or atypical presentations, sometimes only detected if a pleural effusion is large enough to cause symptoms 6.
• Malignancy or asbestos exposure: Can be asymptomatic or present with mild symptoms 2, 5.

Types of Pleurisy

The classification of pleurisy is based on its underlying cause, clinical presentation, and pathological features. Recognizing the type is vital for appropriate management.

Type	Distinguishing Feature	Common Causes	Source(s)
Primary Pleurisy	Occurs as main disease	Infectious, idiopathic	3, 4
Secondary Pleurisy	Occurs secondary to other diseases	Autoimmune, malignancy, etc.	3, 6
Exudative Pleurisy	Pleural effusion with high protein	TB, infection, autoimmune	4, 6
Tuberculous Pleurisy	Pleurisy caused by TB infection	Mycobacterium tuberculosis	3, 4, 7
Malignant Pleurisy	Associated with cancer	Lung, breast, other cancers	5
Asbestos-related Pleurisy	Linked to asbestos exposure	Occupational/environmental	2
Empyema	Collection of pus in pleural space	Complicated infection	5, 11

Table 2: Major Types of Pleurisy

Primary vs. Secondary Pleurisy

• Primary pleurisy refers to cases where the pleural inflammation is the main disease process, often due to infections (viral, bacterial) or idiopathic (unknown) causes 3.
• Secondary pleurisy develops as a complication of other systemic diseases—such as autoimmune disorders (rheumatoid arthritis, lupus), malignancy, or even trauma 3, 6.

Exudative vs. Transudative Pleurisy

• Exudative pleurisy involves effusions rich in proteins and cells, often resulting from infections (like tuberculosis or pneumonia) or inflammatory diseases 4, 6.
• Transudative effusions (not true pleurisy) are usually due to heart failure or cirrhosis and reflect systemic fluid shifts rather than local pleural inflammation.

Tuberculous Pleurisy

This form is a classic example of exudative pleurisy and remains a significant health concern in many parts of the world. TB pleurisy may be acute or, rarely, chronic (caseous pleurisy or tuberculous empyema) 4. Diagnosis often relies on pleural fluid analysis, biopsy, and cultures 4, 11.

Malignant and Asbestos-related Pleurisy

• Malignant pleurisy results from direct invasion or metastatic spread of tumors to the pleura, most commonly lung or breast cancers. It is a common cause of pleural disease in adults 5.
• Asbestos-related pleurisy encompasses several forms, including exudative pleurisy, pleural plaques, and progressive pleural fibrosis. Many cases are asymptomatic and identified incidentally 2.

Empyema

A severe form of pleural infection where pus accumulates in the pleural cavity. This can lead to significant morbidity and requires prompt intervention 5, 11.

Causes of Pleurisy

Pleurisy is not a disease in itself, but a manifestation of various underlying conditions. Identifying the cause is essential for effective treatment.

Cause Category	Example Conditions	Mechanism/Trigger	Source(s)
Infectious	Bacterial, viral, TB	Direct infection of pleura	1, 3, 4
Autoimmune/CTD	RA, lupus, systemic sclerosis	Immune-mediated inflammation	6
Malignancy	Lung, breast cancer	Tumor invasion or metastasis	5
Environmental	Asbestos exposure	Chronic irritation, fibrosis	2
Cardiopulmonary	Pulmonary embolism, heart failure	Infarction/effusion	1, 4
Trauma/Surgery	Rib fracture, procedures	Direct injury to pleura	4
Idiopathic	Unknown	No clear cause identified	3

Table 3: Common Causes of Pleurisy

Infectious Causes

• Viral infections: Viruses such as influenza, Coxsackie, or even SARS-CoV-2 (COVID-19) can cause pleurisy as an initial or sole presentation 1.
• Bacterial infections: Pneumonia, lung abscess, and empyema are common culprits. Streptococcus and Staphylococcus species are frequent offenders 5, 11.
• Tuberculosis: TB is a classic cause, especially in endemic regions. It typically leads to an exudative effusion and may be the only sign of TB in some patients 3, 4, 7.

Autoimmune and Systemic Diseases

• Connective tissue diseases (CTDs): Conditions like rheumatoid arthritis and systemic lupus erythematosus frequently involve the pleura, causing exudative pleurisy. Other CTDs are less commonly implicated 6.
• Mechanism: Immune-mediated inflammation damages the pleura, leading to effusion and pain.

Malignancy

• Direct involvement: Tumors can invade or metastasize to the pleura, causing malignant pleurisy. Lung and breast cancers are most common, but any cancer can potentially cause it 5.
• Associated effusions: Malignant pleurisy is often accompanied by large, recurrent effusions that may require repeated drainage.

Environmental and Occupational Triggers

• Asbestos exposure: Chronic inhalation of asbestos fibers can cause pleural plaques, effusions, and long-term fibrosis. Symptoms are often absent, and changes may be detected only with imaging 2.

Cardiopulmonary and Other Causes

• Pulmonary embolism: Infarction of lung tissue can lead to localized pleurisy.
• Heart failure: Transudative effusions may occur, though not strictly pleurisy unless there is concurrent inflammation 4.

Idiopathic and Iatrogenic Causes

• Idiopathic: In some cases, no clear cause is identified; these are termed idiopathic pleurisy 3.
• Trauma or surgery: Injury to the chest wall or pleura during surgery or from trauma can also result in pleurisy 4.

Treatment of Pleurisy

Treatment of pleurisy is highly individualized, depending on the underlying cause, severity of symptoms, and patient health status. Both supportive and cause-specific therapies are employed.

Treatment	Purpose/Indication	Key Points/Outcomes	Source(s)
Analgesia	Relieve pleuritic pain	NSAIDs, opioids as needed	1, 4
Treat underlying cause	Eradicate infection, control disease	Antibiotics, antivirals, anti-TB drugs	4, 5, 7
Drainage	Remove effusion/empyema	Chest tube, thoracentesis	7, 8, 11
Corticosteroids	Reduce inflammation (select cases)	Used in TB pleurisy/autoimmune; benefit debated	7, 10
Intrapleural therapy	Break down pus/adhesions in empyema	tPA/DNase therapy, reduces surgery need	8
Supportive care	Oxygen, fluids, rest	For hypoxemia, systemic illness	1, 11

Table 4: Main Treatment Approaches

Symptom Relief

• Analgesics: Pain control is essential. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used, with opioids for severe cases 1, 4.
• Supportive measures: Oxygen therapy may be needed if hypoxemia is present, and rest is recommended during the acute phase 1.

Addressing the Underlying Cause

• Infectious pleurisy: Antibiotics (for bacterial infections), antivirals (for viral causes), or anti-tuberculosis drugs (for TB) are used as appropriate 4, 5, 7. Prompt and appropriate therapy is crucial to prevent complications.
• Autoimmune pleurisy: Immunosuppressive drugs may be needed in cases linked to connective tissue diseases 6.

Drainage Procedures

• Thoracentesis: Removal of pleural fluid via needle aspiration can relieve symptoms and aid in diagnosis.
• Chest tube drainage: Required for large effusions or empyema. Complete drainage is associated with better symptomatic improvement in TB pleurisy 7.
• Surgical intervention: Reserved for complicated cases not amenable to medical therapy.

Intrapleural Therapies

• tPA/DNase therapy: In empyema, a combination of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) can break down pus and adhesions, improving outcomes and reducing the need for surgery. This therapy is effective and generally well-tolerated 8.

Role of Corticosteroids

• Tuberculous pleurisy: The use of steroids remains controversial. Some studies suggest a reduction in residual pleural thickening and faster radiological resolution, but no clear long-term functional benefit and a potential for increased adverse effects, particularly in HIV-positive patients 7, 10.
• Autoimmune pleurisy: Steroids may be useful to control inflammation in cases related to systemic diseases 6.

New and Experimental Treatments

• Antioxidants/anti-inflammatories: Experimental agents like isoliquiritigenin have shown promise in animal models by reducing pleural inflammation and oxidative stress 9.

Monitoring and Follow-up

• Imaging: Repeat imaging may be necessary to monitor resolution of effusion and detect complications.
• Pulmonary function: Long-term follow-up is important, especially in TB pleurisy, to assess for lung restriction or fibrosis 10.

Conclusion

Pleurisy is a multifaceted condition with a variety of causes, clinical presentations, and treatment options. Early recognition and targeted management are essential for optimal outcomes.

Key points from this article:

• Pleurisy most commonly presents with sharp, pleuritic chest pain but can also be asymptomatic, especially in asbestos-related cases.
• Types of pleurisy include primary, secondary, exudative, tuberculous, malignant, and empyema, each with distinct clinical features and management needs.
• Causes range from infections and autoimmune diseases to malignancy, environmental exposures, and trauma.
• Treatment is tailored to the underlying cause and may include pain relief, drainage, antibiotics, corticosteroids (select cases), and advanced intrapleural therapies.
• Recent research supports the use of tPA/DNase therapy in empyema and ongoing investigation into the role of corticosteroids and novel anti-inflammatories.
• Long-term monitoring is important for preventing and addressing complications such as pleural thickening and reduced lung function.

By understanding the diverse manifestations, causes, and treatment approaches for pleurisy, clinicians and patients alike can work towards faster diagnosis, more effective therapy, and better overall health outcomes.