Definition and epidemiology
Pleurisy (pleuritis) refers to inflammation of the pleura, the two-layered serous membrane lining the lungs (visceral pleura) and chest wall (parietal pleura). Inflammation causes the normally smooth, lubricated pleural surfaces to become roughened, producing friction and sharp pain with respiratory movement.
Pleurisy itself is a clinical syndrome rather than a single disease, so true incidence is hard to pin down, but it is a common cause of acute chest pain presentations, especially in young and otherwise healthy patients with a preceding viral illness. It can occur at any age and affects males and females similarly, with the underlying cause often dictating the demographic (e.g., autoimmune pleuritis skews toward younger women, malignant pleuritis toward older adults with cancer risk factors).
- Pleuritic chest pain is sharp, worsens with inspiration/cough, and improves with breath-holding or splinting
- Pleural friction rub is pathognomonic and best heard at the lung bases during both inspiration and expiration
- The friction rub disappears once a pleural effusion separates the visceral and parietal pleura
- Viral infection is the most common cause of isolated pleurisy in young healthy patients
- Always consider PE in new pleuritic chest pain, especially with risk factors for VTE
- Light's criteria distinguish exudative from transudative pleural effusions when thoracentesis is performed
- Autoimmune disease (SLE, RA) and malignancy are key causes to exclude in recurrent or atypical pleurisy
- NSAIDs are first-line symptomatic therapy; treatment of the underlying cause determines long-term outcome
Etiology and risk factors
- Viral infection (most common): coxsackievirus, echovirus, influenza, adenovirus
- Bacterial pneumonia with parapneumonic pleural involvement
- Pulmonary embolism with pleural infarction
- Autoimmune disease: systemic lupus erythematosus, rheumatoid arthritis
- Malignancy: lung cancer, mesothelioma, metastatic disease, lymphoma
- Tuberculosis
- Post-cardiac injury syndrome / Dressler syndrome after MI or cardiac surgery
- Trauma or rib fracture
- Uremia in renal failure
- Drug-induced lupus (hydralazine, procainamide, isoniazid)
Risk factors mirror those of the underlying cause: recent viral illness, smoking and cancer risk factors, immobility or hypercoagulability (for PE), known autoimmune disease, or recent cardiothoracic surgery.
Pathophysiology
The parietal pleura is richly innervated by intercostal nerves and is pain-sensitive, while the visceral pleura is not. Inflammation (infectious, autoimmune, neoplastic, or ischemic) causes the pleural surfaces to lose their normal thin layer of lubricating fluid and become fibrin-coated and roughened.
As the lungs expand and contract, the inflamed, roughened parietal and visceral pleural surfaces rub against each other, generating the characteristic friction rub and sharp pain. If inflammation increases vascular permeability, exudative pleural fluid can accumulate (pleural effusion), which paradoxically may reduce pain by separating the two pleural layers, even as it causes dyspnea.
Clinical features
Symptoms
- Sharp, stabbing chest pain, typically unilateral
- Pain worsens with inspiration, coughing, sneezing, or movement
- Pain improves with shallow breathing or splinting (lying on the affected side)
- Pain may radiate to the shoulder or back if diaphragmatic pleura is involved
- Associated symptoms from the underlying cause: fever, cough, dyspnea (pneumonia); hemoptysis, leg swelling (PE); joint pain, rash (lupus)
Signs
- Pleural friction rub: a grating, leathery sound heard on auscultation during both inspiration and expiration, best heard at the lung bases
- Shallow, rapid breathing to minimize pain
- Decreased breath sounds and dullness to percussion if a pleural effusion develops (rub may disappear once fluid separates the pleural layers)
- Fever, tachycardia depending on cause
Diagnosis
Pleurisy is primarily a clinical diagnosis based on history and the finding of a pleural friction rub, but workup focuses on identifying the underlying cause.
Initial evaluation
- History and physical exam: character of pain, associated symptoms, risk factors for PE, autoimmune or malignancy history
- Chest X-ray: often normal in isolated pleurisy; may show effusion, infiltrate, or mass
- ECG: to exclude pericarditis and cardiac causes of chest pain
- Basic labs: CBC, inflammatory markers (ESR, CRP)
Further workup depending on suspicion
- D-dimer / CT pulmonary angiography if PE is suspected
- ANA, rheumatoid factor, anti-dsDNA if autoimmune disease suspected
- Pleural fluid analysis (thoracentesis) if effusion present: cell count, protein, LDH, glucose, pH, cytology, Gram stain and culture
- Light's criteria to distinguish exudate from transudate
- CT chest if malignancy or complicated pneumonia suspected
Differential diagnosis
| Condition | Distinguishing feature |
|---|---|
| Pericarditis | Pain relieved by sitting forward; pericardial friction rub; diffuse ST elevation |
| Musculoskeletal chest pain (costochondritis) | Reproducible with palpation of chest wall |
| Pulmonary embolism | Dyspnea, tachycardia, risk factors for VTE, may coexist with pleurisy |
| Pneumothorax | Sudden onset, decreased breath sounds, hyperresonance |
| Acute coronary syndrome | Pressure-like pain, exertional, ECG/troponin changes |
| Herpes zoster (pre-rash) | Dermatomal distribution, vesicular rash appears later |
| GERD | Burning, related to meals, relieved by antacids |
Management
Management has two goals: symptomatic relief of pleuritic pain and treatment of the underlying cause.
Symptomatic treatment
- NSAIDs (e.g., ibuprofen, indomethacin) are first-line for pain relief
- Acetaminophen as an alternative or adjunct if NSAIDs are contraindicated
- Short-term opioid analgesia only rarely, for severe refractory pain
- Encourage normal breathing and gentle activity to prevent atelectasis, despite discomfort
Cause-directed treatment
- Viral pleurisy: supportive care, usually self-limited
- Bacterial pneumonia with parapneumonic effusion: antibiotics; drainage (chest tube) if empyema or complicated effusion
- Pulmonary embolism: anticoagulation per standard PE protocols
- Autoimmune pleuritis (lupus, RA): NSAIDs first, systemic corticosteroids or disease-modifying agents for refractory or recurrent disease
- Tuberculous pleuritis: standard anti-tuberculous multidrug thertherapy
- Malignant pleuritis: treatment of underlying malignancy; therapeutic thoracentesis or pleurodesis for symptomatic effusions
- Uremic pleuritis: optimize dialysis
Large or symptomatic pleural effusions may require thoracentesis for both diagnostic and therapeutic purposes regardless of cause.
Complications and prognosis
Most cases of viral or idiopathic pleurisy are self-limited and resolve within days to a couple of weeks without sequelae. Prognosis in secondary pleurisy depends entirely on the underlying cause.
Potential complications
- Pleural effusion, which may become loculated or infected (empyema)
- Pleural thickening or fibrosis, occasionally restrictive if extensive
- Chronic pain from pleural adhesions in rare cases
- Complications of the underlying disease (e.g., respiratory failure from large malignant effusion, sepsis from empyema)
Recurrent pleurisy should prompt a thorough search for autoimmune disease, malignancy, or recurrent PE rather than being attributed to idiopathic causes.
Causes of pleurisy — PLEURA: Pneumonia, Lupus/RA, Embolism (PE), Uremia, Rib fracture/trauma, Abscess/TB or malignancy
Practice questions
1. A 24-year-old man presents with 2 days of sharp left-sided chest pain that worsens with deep breathing and coughing. He had a cold with cough and sore throat last week. Vital signs are normal except mild tachypnea. On auscultation, a grating sound is heard over the left lower lung field during both inspiration and expiration. Chest X-ray is normal. What is the most likely diagnosis?
2. A 45-year-old woman with a history of systemic lupus erythematosus presents with recurrent episodes of sharp chest pain worsened by breathing. Chest X-ray shows a small left pleural effusion. Thoracentesis reveals an exudative fluid with elevated ANA titer and low complement levels. Which of the following is the most appropriate initial treatment?
3. A 68-year-old man with a 40-pack-year smoking history presents with pleuritic chest pain, weight loss, and a large unilateral pleural effusion. Thoracentesis reveals bloody exudative fluid with malignant cells on cytology. Which management is most appropriate for his symptomatic large effusion?
Frequently asked questions
What causes pleurisy?
Pleurisy is most often caused by viral infection, especially in young healthy people, but it can also result from bacterial pneumonia, pulmonary embolism, autoimmune disease such as lupus or rheumatoid arthritis, tuberculosis, malignancy, chest trauma, or post-cardiac injury syndrome. Identifying the underlying cause is the main focus of evaluation, since isolated viral pleurisy is usually self-limited while other causes need specific treatment.
What are the first symptoms of pleurisy?
The first symptom is usually sudden, sharp, stabbing chest pain on one side that gets worse with deep breathing, coughing, or sneezing. Patients often breathe shallowly or hold their chest to minimize movement, and pain may improve when lying on the affected side. Fever, cough, or shortness of breath may accompany it depending on the underlying cause.
How is pleurisy diagnosed?
Pleurisy is mainly diagnosed clinically through history and finding a pleural friction rub on chest auscultation. A chest X-ray, ECG, and basic blood tests are typically obtained to look for an underlying cause and rule out mimics like pericarditis or pneumothorax, with further tests such as CT pulmonary angiography, autoimmune panels, or thoracentesis guided by clinical suspicion.
Is pleurisy curable?
Yes, isolated viral or idiopathic pleurisy typically resolves completely within days to about two weeks with supportive care and NSAIDs. When pleurisy is secondary to another condition such as pneumonia, PE, or autoimmune disease, resolution depends on successfully treating that underlying cause, and recurrence can happen if the trigger persists or returns.
Pleurisy vs pericarditis — what is the difference?
Pleurisy causes pain worsened by breathing and coughing with a pleural friction rub heard at the lung bases, while pericarditis causes pain that is relieved by sitting forward and worsened by lying flat, with a pericardial friction rub and often diffuse ST-segment elevation on ECG. The two can coexist, particularly in autoimmune disease or post-cardiac injury syndrome, so ECG is key to distinguishing them.
Key drugs
Related conditions and differentials
Sources and further reading
StatPearls (NCBI Bookshelf)MedlinePlusWHO ICD-10: J90
Educational content for medical students, prepared by the WhiteCoat Pro editorial team with AI assistance; every page is reviewed by a second AI model for factual errors. It is not medical advice and does not replace the product label, local guidelines or a clinician.