Pleurisy and Pleural Effusion

What Is It?

Pleurisy means inflammation of the pleura, the membrane that covers the lungs and lines the inside of the chest cavity. Depending on its cause, pleurisy can be associated with an accumulation of fluid in the space between the lungs and chest wall called a pleural effusion, or it can be dry pleurisy, which has no fluid accumulation.

Pleurisy can develop many ways, including:

• Lung infection. In industrialized nations, bacterial pneumonia (lung infection) resulting from staphylococci, pneumococci, Haemophilus influenzae or other organisms is a frequent cause of pleurisy. In developing nations where tuberculosis is common, pulmonary tuberculosis is another important cause. When pleurisy is caused by a bacterial lung infection, it can be associated with a pus-filled pleural effusion. Viral lung infections, especially epidemic pleurodynia (an infection usually caused by coxsackieviruses or echoviruses), also can cause pleurisy.

• Pulmonary embolism. A pulmonary embolism is a blood clot that has floated through the bloodstream and lodged in the lungs. In people with pulmonary embolism, symptoms of pleurisy tend to occur when the pulmonary embolism is fairly small and has lodged in a part of the lungs near the pleura.

• Lung cancer. Pleurisy can develop in people with lung cancer. When pleurisy occurs because of lung cancer, a bloody pleural effusion is common.

• Rheumatic fever. Rheumatic fever, an inflammatory condition that sometimes occurs after a streptococcal infection, can cause pleurisy, as well as inflammation in other parts of the body, including the heart and joints.

• Connective tissue disorders. Systemic lupus erythematosus (SLE or lupus) and other connective tissue disorders can cause inflammation of the pleura.

• Rare causes. Radiation therapy (for cancer), a collapsed lung (pneumothorax) and pericarditis (as with severe kidney failure or following a heart attack) all can be associated with pleurisy.

• No identifiable cause. Pleurisy can develop for no clear reason despite extensive investigation. These cases are rare, and usually are presumed to be caused by a viral infection.

Symptoms

Pleurisy typically causes a sharp chest pain (pleuritic chest pain) that worsens with breathing in or coughing. The pain may start and remain in one specific area of the chest wall, or it may spread to the shoulder or back. To ease chest pain from pleurisy, a person with pleurisy often lies on the affected side as a way of limiting movement of the chest wall. In rare cases, the chest pain of pleurisy is a fairly constant, dull ache.

Depending on the specific cause of pleurisy, other symptoms may be present. For example, a person with pneumonia may have a high fever, shortness of breath and a cough that produces thick, yellow or dark sputum (mucus). A pulmonary embolus may be associated with shortness of breath, a low-grade fever and a cough that brings up small amounts of blood. A person with lung cancer may have unexplained weight loss and cough and a strong history of smoking. People with rheumatic fever may have pain and swelling in several joints that follow a sore throat.

Diagnosis

Your doctor will ask about your medical history, including your history of smoking. He or she also may ask whether you have been anywhere where you may have been exposed to tuberculosis. To confirm the diagnosis, he or she will examine you, paying special attention to your lungs. Your doctor will check for signs of pleural effusion by gently tapping your chest wall. He or she also will listen with a stethoscope to check for a pleural friction rub, the rough, scratchy sound of the inflamed layers of pleura sliding past each other during breathing. Depending on the results of your physical examination and the suspected cause of your pleurisy, the doctor then may recommend:

• A chest X-ray. This can show areas of pneumonia, pulmonary tuberculosis, pulmonary embolism, pleural effusion or a cancerous nodule.
• Blood tests. Specific blood tests can be used to help diagnose pneumonia, rheumatic fever, pulmonary embolism and lupus.
• Ultrasound or computed tomography (CT) --If your doctor suspects a pleural effusion, an ultrasound or CT scan of the chest can confirm that there is an abnormal pocket of fluid in the lungs.

Depending on the results of these preliminary tests, additional tests may be necessary to confirm the diagnosis. For example, in patients with suspected pulmonary embolism, a lung scan or CT scan of the lungs may be used to confirm the diagnosis. A patient with confirmed pleural effusion may require a procedure called thoracentesis, in which some chest fluid is removed and sent to a laboratory to be tested.

Expected Duration

How long pleurisy lasts depends on its cause. For example, pleurisy caused by pleurodynia may come and go over a few days. In rare cases, a person with pleurodynia may have several episodes of pleuritic chest pain over several weeks before the illness finally goes away. In patients with bacterial pneumonia or rheumatic fever, pleurisy typically goes away when the infection is cured with antibiotics. In patients with lung cancer or connective tissue disease, the chest pain of pleurisy may persist for longer periods.

Prevention

In some cases, you can prevent pleurisy by preventing the medical condition that causes it. For example, some types of pneumonia can be prevented by vaccination. Rheumatic fever can be prevented by prompt antibiotic treatment of strep throat. The risk of lung cancer is reduced by not smoking.

Not all cases of pleurisy can be prevented.

Treatment

The treatment of pleurisy depends on its underlying cause:

• Lung infection. Pleurisy caused by bacterial pneumonia is treated with antibiotics. Pulmonary tuberculosis is treated with antituberculosis drugs. Because pleurodynia is a viral infection, it does not respond to antibiotic treatment. However, most people with pleurodynia recover on their own without complications. When there is a large pleural effusion, the doctor may drain the accumulated fluid, allowing the patient to breathe more comfortably and efficiently. Pain medication also can improve the patient's ability to breathe, because it relieves chest discomfort. In some patients, oxygen therapy also is necessary.

• Pulmonary embolism. A small pulmonary embolism can be treated with anticoagulants, drugs that thin the blood and prevent future blood clots. Large pulmonary emboli may be treated with thrombolytic medications, drugs that dissolve blood clots.

• Lung cancer. Treatments include surgical removal of all or part of a lung, radiation and chemotherapy.

• Rheumatic fever. Rheumatic fever is treated with antibiotics (usually penicillin) to kill strep bacteria, together with aspirin or other anti-inflammatory drugs to reduce inflammation. Additional treatments may be needed for people with severe cardiac or neurological symptoms.

• Connective tissue disorders. The pleurisy of lupus can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil, Motrin), or with corticosteroids, such as prednisone (sold under several brand names), hydrocortisone (Cortef, Hydrocortone), methylprednisolone or dexamethasone (both sold under several brand names). Medications that suppress the immune system to control the underlying connective tissue disease will often help to control the pleural inflammation.

When to Call a Professional

Call your doctor immediately or go to an emergency room if you experience any form of severe or persistent chest pain or any difficulty breathing. Chest pain can be a symptom of many different disorders, some of which are potentially life threatening.

Prognosis

In patients with pleurisy, the outlook depends on the underlying medical illness.

• Lung infection. People with epidemic pleurodynia or other viral cause of pleurisy have an excellent prognosis. Patients with bacterial pneumonia also have a good prognosis if they promptly receive proper antibiotic treatment, especially if they are young and otherwise healthy.

• Pulmonary embolism. When a small pulmonary embolism affects less than 30% of the lungs, the prognosis is excellent. For large or recurrent emboli, respiratory problems or bleeding can occur in the future as a result of lung damage and the risks of long-term treatment with blood thinners.

• Lung cancer. The prognosis for lung cancer depends on whether the cancer is started in the lungs or spread there from another site in the body, how much lung tissue is involved, and whether the lung cancer has spread to other tissues and organs. Although the overall prognosis for people with lung cancer is poor, the outlook is best for those with small, localized tumors that are detected early.

• Rheumatic fever. In most cases, rheumatic fever has a good prognosis. Recurrence is most common in the first five years after the initial rheumatic fever episode.

• Connective tissue disorders. The outlook for people with pleurisy resulting from lupus is good, but the overall prognosis depends on whether other major organs, such as the kidney, are affected by the disease.

Additional Info

American Lung Association
61 Broadway, 6th Floor
New York, NY 10006
Phone: 212-315-8700
Toll-Free: 1-800-548-8252http://www.lungusa.org/

National Heart, Lung, and Blood Institute (NHLBI)
P.O. Box 30105
Bethesda, MD 20824-0105
Phone: 301-592-8573
TTY: 240-629-3255
Fax: 301-592-8563
http://www.nhlbi.nih.gov/

National Cancer Institute (NCI)
Public Inquiries Office
Building 31
Room 10A03
31 Center Drive, MSC 8322
Bethesda, MD 20892-2580
Phone: 301-435-3848
Toll-Free: 1-800-422-6237
TTY: 1-800-332-8615
http://www.nci.nih.gov/

American Cancer Society (ACS)
1599 Clifton Road, NE
Atlanta, GA 30329-4251
Toll-Free: 1-800-227-2345
http://www.cancer.org/

Lupus Foundation of America
2000 L St., N.W.
Suite 710
Washington, D.C. 20036
Phone: 202-349-1155
Toll-Free: 1-800-558-0121
Fax: 202-349-1156
http://www.lupus.org/