A sudden, sharp, stabbing pain in your chest with every breath can be a frightening and intense experience. The pain may force you to take shallow breaths and can make coughing or sneezing feel agonizing. This type of pain is the hallmark symptom of pleurisy, a condition where the delicate tissues that line your lungs and chest cavity become inflamed. It is crucial to understand that pleurisy is not a disease itself, but rather a sign, a painful warning that there is an underlying medical condition causing this inflammation. Because the causes can range from a common viral infection to a life-threatening blood clot in the lungs, any new onset of pleuritic chest pain warrants a prompt medical evaluation to determine the root cause and receive the right treatment.

Pleurisy, known medically as pleuritis, is pleural inflammation. The pleura is a thin, two-layered membrane that plays a vital role in the mechanics of breathing.

• The visceral pleura is the layer that directly covers the outside surface of each lung.
• The parietal pleura is the layer that lines the inside of the chest wall.

Between these two layers is a very thin, fluid-filled space called the pleural space. This small amount of lubricating fluid allows the two layers to glide smoothly against each other with every breath, ensuring that the lungs can expand and contract effortlessly and without friction.

A helpful analogy is to think of your lungs as two smooth silk balloons inside a silk-lined box.

• The lubricating fluid between the balloon and the box lining allows for silent, painless movement.
• In pleurisy, it is as if the silk lining of the box (the parietal pleura) has become inflamed and covered in rough, gritty sandpaper.
• Now, every time the balloon inflates and deflates with each breath, it scrapes against this painful, sandpaper-like surface. This friction is what causes the characteristic sharp, stabbing pain of pleurisy.

This is why the pain is specifically tied to the movement of the chest wall, it is worse with deep breathing, coughing, sneezing, or even talking, and is often relieved by holding one’s breath or lying on the painful side to limit movement.

In my experience, patients often describe pleurisy as a “sharp, stabbing pain” that worsens with breathing. It’s one of the more alarming but commonly misunderstood chest pains.

The direct cause of pleurisy is the inflammation of the parietal pleura. The underlying causes are the many different medical conditions that can cause this inflammation.

Infections

This is the most common cause of pleurisy.

• Viral Infections: Most cases of simple pleurisy are caused by common viral infections, such as influenza (the flu), coxsackievirus, or Epstein-Barr virus. The virus causes a mild, self-limited inflammation of the pleura.
• Bacterial Pneumonia: An infection within the lung tissue can spread to the adjacent pleural space, causing inflammation and pleurisy.
• Tuberculosis (TB): In many parts of the world, tuberculosis is a significant cause of pleurisy and the accumulation of fluid in the pleural space.

Vascular Conditions

• Pulmonary Embolism (PE): This is one of the most dangerous causes of pleurisy and is a true medical emergency. A pulmonary embolism occurs when a blood clot, usually from the deep veins of the legs, breaks off and travels to the lungs, lodging in a pulmonary artery. This can cut off blood flow to a portion of the lung tissue, leading to tissue death (infarction) and intense inflammation of the overlying pleura.

Autoimmune Diseases

In these conditions, the body’s own immune system attacks its own tissues, including the pleura.

• Lupus (Systemic Lupus Erythematosus)
• Rheumatoid Arthritis

Cancers

• Lung Cancer that is near the surface of the lung can invade and inflame the pleura.
• Metastatic Cancer: Cancer that has spread to the pleura or lung from another body part, such as breast cancer.

Other Causes

• Chest Trauma: A fractured rib can directly irritate the pleura.
• Complications from Heart Surgery, particularly coronary artery bypass grafting.
• Certain Medications can rarely cause a lupus-like syndrome that includes pleurisy.
• Pancreatitis or a Subphrenic Abscess: Inflammation from nearby abdominal organs can sometimes irritate the diaphragm and the pleura above it.

A person develops pleurisy as a symptom of one of the underlying conditions listed above. It is not something you can “get” on its own. The pleurisy risk factors are the risk factors for these various diseases. For example, risk factors for a pulmonary embolism include recent surgery, prolonged immobility, or a history of blood clots. The risk factor for infectious pleurisy is exposure to the specific virus or bacterium causing the illness.

Clinically, I’ve seen it triggered by a wide range of causes from infections and blood clots to cancer or even post-surgical complications, so identifying the root cause is essential.

The primary and defining symptom of pleurisy is a specific type of chest pain.

Pleuritic Chest Pain

The hallmark symptom of pleurisy is a chest pain that is:

• Sharp, stabbing, or “catching” in nature.
• Localized to a specific area of the chest, back, or shoulder.
• Worse with respiratory movement. The pain is significantly aggravated by taking a deep breath, coughing, sneezing, laughing, or moving the torso.
• Relieved by holding the breath or taking very shallow breaths.

Associated Symptoms

A person with pleurisy will often have other symptoms related to the underlying cause.

• Shortness of Breath (Dyspnea): This can be due to the person consciously taking shallow breaths to avoid the pain, or it can be a sign of the underlying condition itself, such as pneumonia or a pulmonary embolism.
• A Dry, Hacking Cough.
• Symptoms of Infection: If the cause is infectious, the person will likely have a fever, chills, and body aches.
• Pleural Effusion: In some cases, inflammation can lead to a buildup of excess fluid in the pleural space. This is called a pleural effusion. As the fluid builds up, it can separate the two inflamed pleural layers, which may relieve the rubbing pain. However, a large effusion will compress the lung, leading to a worsening shortness of breath and a feeling of heaviness in the chest.

Clinically, I also look for shallow breathing, a pleural friction rub on auscultation and accompanying symptoms like fever or cough depending on the underlying condition.

Because the causes of pleuritic chest pain range from benign to life-threatening, it is a symptom that always warrants a medical evaluation. The goal of the diagnostic workup is not to diagnose the pleurisy itself, but to find the underlying cause.

1. Medical History and Physical Examination: The doctor will ask detailed questions about the nature of the pain and any other symptoms. The most important diagnostic step during the physical exam is listening to the chest with a stethoscope. A doctor may hear a distinctive “pleural friction rub,” a leathery, creaking, or grating sound that is produced by the two inflamed pleural layers rubbing against each other with each breath.
2. Imaging Studies:
   • Chest X-ray: This is almost always the first imaging test performed. It can reveal many causes of pleurisy, such as pneumonia, a rib fracture, a lung tumor, or a pleural effusion.
   • Computed Tomography (CT) Scan: A CT scan provides much more detailed images of the lungs, pleura, and blood vessels. A CT angiogram (CTA), which involves injecting contrast dye, is the gold standard test to diagnose a pulmonary embolism.
   • Ultrasound: A chest ultrasound is very effective at identifying and locating a pleural effusion.
3. Blood Tests: Blood tests are done to look for signs of infection (a high white blood cell count) or inflammation (high levels of CRP and ESR). A blood test called a D-dimer may be used to help assess the likelihood of a blood clot.
4. Thoracentesis: If a significant pleural effusion is present, this procedure is often performed for both diagnostic and therapeutic purposes. A doctor uses a sterile needle to drain a sample of the fluid from the pleural space. This fluid is then sent to a laboratory to be analyzed for signs of infection, cancer cells, or other clues that can reveal the underlying cause.

In my experience, identifying the underlying cause is key, so I often order blood tests, ECGs, and D-dimer if I suspect pulmonary embolism.

Pleurisy treatment is entirely focused on treating the underlying disease that is causing the inflammation. There is no treatment for the pleural inflammation itself, except pain management.

The treatment plan will be tailored to the specific diagnosis.

• For Infections:
  • Bacterial Pneumonia or TB will be treated with the appropriate antibiotic course.
  • Viral pleurisy is self-limited and requires no specific treatment other than rest and pain control. The inflammation will resolve on its own as the body clears the virus.
• For a Pulmonary Embolism: Treatment involves hospitalization and the use of anticoagulant medications (blood thinners) to dissolve the clot and prevent new ones from forming.
• For Autoimmune Diseases: Treatment will be managed by a rheumatologist and will involve immunosuppressive medications, such as corticosteroids, to control the underlying autoimmune response.
• For Cancer: Treatment will be managed by an oncologist.

Symptomatic Relief

While the underlying cause is being treated, medications are used to control the pleuritic chest pain.

• Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Medications like ibuprofen are the mainstay of treatment. They are effective in reducing pleural pain and inflammation.
• Rest: Getting adequate rest and finding a comfortable position (often lying on the painful side) can help to minimize pain.
• Cough Suppressants: If a persistent, dry cough is making the pain worse, a doctor may prescribe a codeine-based cough syrup for temporary relief.

I’ve seen mild viral pleurisy resolve with rest, anti-inflammatory medications, and supportive care, treatment always depends on the underlying cause.

Pleurisy is the sharp, stabbing chest pain that occurs when the delicate lining of the lungs and chest wall becomes inflamed. While the pain itself can be severe and frightening, it is important to remember that pleurisy is a symptom, not a disease. It is a signal that there is an underlying medical issue that needs to be investigated. The causes are diverse, ranging from a common viral infection that will resolve on its own, to a serious and life-threatening condition like a pulmonary embolism. Any new onset of sharp chest pain that worsens with deep breathing or coughing warrants a prompt medical evaluation. Clinically, I’ve found that managing pleurisy early prevents complications like pleural effusion or respiratory distress, especially in high-risk patients.

1. The Mayo Clinic. (2022). Pleurisy. Retrieved from https://www.mayoclinic.org/diseases-conditions/pleurisy/symptoms-causes/syc-20351863
2. The Cleveland Clinic. (2022). Pleurisy. Retrieved from https://my.clevelandclinic.org/health/diseases/14735-pleurisy
3. American Lung Association. (2023). Pleurisy. Retrieved from https://www.lung.org/lung-health-diseases/lung-disease-lookup/pleurisy