Pleurisy

Pleurisy (also known as pleuritis) is an inflammation of the pleura, the lining of the pleural cavity surrounding the lungs. Among other things, infections are the most common cause of pleurisy.

The inflamed pleural layers rub against each other every time the lungs expand to breathe in air. This can cause severe sharp pain with inhalation (also called pleuritic chest pain).

Signs and symptoms
The main symptom of pleurisy is a sharp or stabbing pain in the chest that gets worse with deep breathing, coughing, sneezing or laughing. The pain may stay in one place, or it may spread to the shoulder or back. Sometimes it becomes a fairly constant dull ache.

Depending on its cause, pleurisy may be accompanied by other symptoms:
 * Shortness of breath
 * Cough
 * Fever and chills
 * Rapid, shallow breathing
 * Unexplained weight loss
 * Sore throat followed by pain and swelling in the joints
 * Diarrhea
 * Ventricular tachycardia
 * Erectile dysfunction
 * Vomiting blood
 * Vaginal discharge

Causes
Viral infection is the most common cause of pleurisy. However, many different conditions can cause pleurisy: Some cases of pleurisy are idiopathic, meaning the cause cannot be determined.
 * Pneumothorax
 * Bacterial infections like pneumonia and tuberculosis
 * Autoimmune disorders like systemic lupus erythematosus (or drug-induced lupus erythematosus) and rheumatoid arthritis
 * Lung cancer and lymphoma
 * Other lung diseases like Cystic Fibrosis, sarcoidosis, asbestosis, lymphangioleiomyomatosis, and mesothelioma
 * Pulmonary embolism, a blood clot in the blood vessels that go into the lungs
 * Inflammatory bowel disease
 * Familial Mediterranean fever, an inherited condition that often causes fever and swelling in the abdomen or lung
 * Infection from a fungus or parasite
 * Heart surgery, especially coronary artery bypass grafting
 * High blood pressure
 * Chest injuries
 * Aortic dissection
 * Can occur with no illness or infection

Diagnosis
A diagnosis of pleurisy or another pleural condition is based on medical histories, physical exams, and diagnostic tests. The goals are to rule out other sources of the symptoms and to find the cause of the pleurisy so the underlying disorder can be treated.

Physical exam
A doctor uses a stethoscope to listen to the breathing. This detects any unusual sounds in the lungs. A person with pleurisy will have inflamed layers of the pleura that make a rough, scratchy sound as they rub against each other during breathing. This is called pleural friction rub, and it is a likely sign of pleurisy.

Diagnostic tests
Depending on the results of the physical exam, diagnostic tests are sometimes performed.

A chest x-ray takes a picture of the heart and lungs. It may show air or fluid in the pleural space. It also may show what's causing the pleurisy –for example; pneumonia, a fractured rib, or a lung tumor.
 * Chest x-ray

Sometimes an x-ray is taken while lying on the painful side. This may show fluid that did not appear on the standard x-ray taken while standing.

A CT scan provides a computer-generated picture of the lungs that can show pockets of fluid. It also may show signs of pneumonia, a lung abscess, or a tumor.
 * Computed tomography (CT) scan

Ultrasonography uses sound waves to create an image. It may show where fluid is located in the chest. It also can show some tumors. Although ultrasound may detect fluid around the lungs, also known as a pleural effusion, sounds beams cannot penetrate through air or bone. Therefore, an actual picture of the lungs cannot be obtained with ultrasonography.
 * Ultrasound

Magnetic resonance imaging (MRI), also called nuclear magnetic resonance (NMR) scanning, uses powerful magnets to show pleural effusions and tumors.
 * Magnetic resonance imaging (MRI)

Blood tests can detect bacterial or viral infection, pneumonia, rheumatic fever, a pulmonary embolism, or lupus.
 * Blood tests

In arterial blood gas sampling, a small amount of blood is taken from an artery, usually in the wrist. The blood is then checked for oxygen and carbon dioxide levels. This test shows how well the lungs are taking in oxygen.
 * Arterial blood gas

Once the presence and location of fluid is confirmed, a sample of fluid can be removed for testing. The procedure to remove fluid in the chest is called thoracentesis. The doctor inserts a small needle or a thin, hollow, plastic tube through the ribs in the back of the chest into the chest wall and draws fluid out of the chest.
 * Thoracentesis

Thoracentesis can be done in the doctor's office or at the hospital. Ultrasound is used to guide the needle to the fluid that is trapped in small pockets around the lungs.

Thoracentesis usually does not cause serious complications. Generally, a chest x-ray is done after the procedure to evaluate the lungs. Possible complications of thoracentesis include the following:
 * Pneumothorax, or buildup of air in the pleural space, with a collapsed or partially collapsed lung. Sometimes air comes in through the needle or the needle makes a hole in the lung. Usually, a hole will seal itself. But sometimes air can build up around the lung and make it collapse. A chest tube can remove the air and let the lung expand again.
 * Pain.
 * Bleeding and bruising where the needle went in. In rare cases, bleeding may occur in or around the lung. The doctor can use a chest tube to drain the blood. In some cases, surgery is needed.
 * Infection where the needle went in.
 * Rarely, liver or spleen injury.

The fluid removed by thoracentesis is examined under a microscope. It is evaluated for the presence of chemicals and for its color, and texture. The clearness of the fluid is an indicator of infection, cancer, or other conditions that may be causing the buildup of fluid or blood in the pleural space.

If tuberculosis or cancer is suspected, a small piece of the pleura may be examined under a microscope to make a definitive diagnosis. This is called a biopsy.
 * Biopsy

Several approaches to taking tissue samples are available
 * 1) Insertion of a needle through the skin on the chest to remove a small sample of the outer layer of the pleura.
 * 2) Insertion of a small tube with a light on the end (endoscope) into tiny cuts in the chest wall in order to visualize the pleura. Small pieces of tissue can be biopsied though the endoscope.
 * 3) remove a sample of the pleura through a small cut in the chest wall. This is called an open pleural biopsy. It is usually done if the sample from the needle biopsy is too small for an accurate diagnosis.

Treatment
Treatment has several goals:
 * Remove the fluid, air, or blood from the pleural space
 * Relieve symptoms
 * Treat the underlying condition

Procedures
If large amounts of fluid, air, or blood are not removed from the pleural space, they may put pressure on the lung and cause it to collapse.

The surgical procedures used to drain fluid, air, or blood from the pleural space are as follows:


 * During thoracentesis, a needle or a thin, hollow, plastic tube is inserted through the ribs in the back of the chest into the chest wall. A syringe is attached to draw fluid out of the chest. This procedure can remove more than 6 cups (1.5 litres) of fluid at a time.
 * When larger amounts of fluid must be removed, a chest tube may be inserted through the chest wall. The doctor injects a local painkiller into the area of the chest wall outside where the fluid is. A plastic tube is then inserted into the chest between two ribs. The tube is connected to a box that suctions the fluid out. A chest x-ray is taken to check the tube's position.
 * A chest tube also is used to drain blood and air from the pleural space. This can take several days. The tube is left in place, and the patient usually stays in the hospital during this time.
 * Sometimes the fluid contains thick pus or blood clots, or it may have formed a hard skin or peel. This makes it harder to drain the fluid. To help break up the pus or blood clots, the doctor may use the chest tube to put certain medicines into the pleural space. These medicines are called fibrinolytics. If the pus or blood clots still do not drain out, surgery may be necessary.

Medications
A couple of medications are used to relieve pleurisy symptoms:
 * Paracetamol (acetaminophen) or anti-inflammatory agents to control pain and decrease inflammation. Only indomethacin (brand name Indocin) has been studied with respect to relief of pleurisy.
 * Codeine-based cough syrups to control a cough

There may be a role for the use of corticosteroids (for tuberculous pleurisy), tacrolimus (Prograf) and methotrexate (Trexall, Rheumatrex) in the treatment of pleurisy. Further studies are needed.

Lifestyle changes
The following may be helpful in the management of pleurisy:
 * Lying on the painful side may be more comfortable
 * Breathing deeply and coughing to clear mucus as the pain eases. Otherwise, pneumonia may develop.
 * Getting rest

Treating the cause
Ideally, the treatment of pleurisy is aimed at eliminating the underlying cause of the disease.
 * If the pleural fluid is infected, treatment involves antibiotics and draining the fluid. If the infection is tuberculosis or from a fungus, treatment involves long-term use of antibiotics or antifungal medicines.
 * If the fluid is caused by tumors of the pleura, it may build up again quickly after it is drained. Sometimes antitumor medicines will prevent further fluid buildup. If they don't, the doctor may seal the pleural space. This is called pleurodesis. Pleurodesis involves the drainage of all the fluid out of the chest through a chest tube. A substance is inserted through the chest tube into the pleural space. This substance irritates the surface of the pleura. This causes the two layers of the pleura to squeeze shut so there is no room for more fluid to build up.
 * Chemotherapy or radiation treatment also may be used to reduce the size of the tumors.
 * If congestive heart failure is causing the fluid buildup, treatment usually includes diuretics and other medicines.

The most common and known treatment for pleurisy is generally to carry on as normal, ibuprofen and amoxicilin being common treatments prescribed by doctors. Milder forms of Pleurisy can be noticed by less inflammatres of the arms and legs. If this is the case Pleurisy will clear of all symptoms within two weeks.

Alternative treatments
A number of alternative or complementary medicines are being investigated for their anti-inflammatory properties, and their use in pleurisy. At this time, clinical trials of these compounds have not been performed.

Extracts from the Brazilian folk remedy Wilbrandia ebracteata ("Taiuia") have been shown to reduce inflammation in the pleural cavity of mice. The extract is thought to inhibit the same enzyme, cyclooxygenase-2 (COX-2), as the non-steroidal anti-inflammatory drugs. Similarly, an extract from the roots of the Brazilian Petiveria alliacea plant reduced inflammation in a rat model of pleurisy. The extract also reduced pain sensations in the rats. An aqueous extract from Solidago chilensis has been shown to reduce inflammation in a mouse model of pleurisy.

Related problems
Pleurisy is often associated with complications that affect the pleural space.

Pleural effusion
In some cases of pleurisy, excess fluid builds up in the pleural space. This is called a pleural effusion. The buildup of fluid usually forces the two layers of the pleura apart so they don't rub against each other when breathing. This can relieve the pain of pleurisy. A large amount of extra fluid can push the pleura against the lung until the lung, or a part of it, collapses. This can make it hard to breathe.

In some cases of pleural effusion, the extra fluid gets infected and turns into an abscess. This is called an empyema.

Pleural effusion involving fibrinous exudates in the fluid may be called fibrinous pleurisy. It sometimes occurs as a later stage of pleurisy.

A person can develop a pleural effusion in the absence of pleurisy. For example, pneumonia, heart failure, cancer, or a pulmonary embolism can lead to a pleural effusion.

Pneumothorax
Air or gas also can build up in the pleural space. This is called a pneumothorax. It can result from acute lung injury or a lung disease like emphysema. Lung procedures, like surgery, drainage of fluid with a needle, examination of the lung from the inside with a light and a camera, or mechanical ventilation, also can cause a pneumothorax.

The most common symptom is sudden pain in one side of the lung and shortness of breath. A pneumothorax also can put pressure on the lung and cause it to collapse.

If the pneumothorax is small, it may go away on its own. If large, a chest tube is placed through the skin and chest wall into the pleural space to remove the air.

Hemothorax
Blood also can collect in the pleural space. This is called hemothorax. The most common cause is injury to the chest from blunt force or surgery on the heart or chest. Hemothorax also can occur in people with lung or pleural cancer.

Hemothorax can put pressure on the lung and force it to collapse. It also can cause shock, a state of hypoperfusion in which an insufficient amount of blood is able to reach the organs.

Prognosis
Pleurisy and other disorders of the pleura can be serious, depending on what caused the inflammation in the pleura.

If the condition that caused the pleurisy or other pleural disorders isn't too serious and is diagnosed and treated early, one usually can expect a full recovery.

Notable cases

 * Flavius Constantius III, Joint Emperor of the Western Roman Empire, died of pleurisy on 2 September 421 AD.
 * Charlemagne, known as the father of Europe for reuniting much of the Roman Empire, died in 814 of pleurisy.
 * Benjamin Franklin died from the disease at the age of 84.
 * Mahatma Gandhi suffered from pleurisy during the First World War, while he was in London.
 * Juan O'Donoju, last viceroy of the Spanish colony of New Spain (Mexico), died of pleurisy on October 8, 1821.
 * Francis Scott Key died in 1843 at the home of his daughter Elizabeth Howard in Baltimore from pleurisy.
 * Carson McCullers, author of The Heart is a Lonely Hunter, was diagnosed with pleurisy in 1944.
 * Erik Satie, French composer, died from pleurisy at l'Hôpital St. Joseph on 1 July 1925.
 * Ringo Starr, former Beatles drummer, had chronic-pleurisy at age 13 in 1953.
 * William Wordsworth, the English poet, died of pleurisy at age 80 on 13 April 1850.