Pleurisy

Pleuritic chest pain is a common presenting symptom and has many causes, which range from life-threatening to benign, self-limited conditions. Pulmonary embolism is the most common potentially life-threatening cause, found in 5 to 20 percent of patients who present to the emergency department with pleuritic pain. Other clinically significant conditions that may cause pleuritic pain include pericarditis, pneumonia, myocardial infarction, and pneumothorax. Patients should be evaluated appropriately for these conditions before an alternative diagnosis is made. History, physical examination, and chest radiography are recommended for all patients with pleuritic chest pain. Electrocardiography is helpful, especially if there is clinical suspicion of myocardial infarction, pulmonary embolism, or pericarditis. When these other significant causes of pleuritic pain have been excluded, the diagnosis of pleurisy can be made. There are numerous causes of pleurisy, with viral pleurisy among the most common. Other etiologies may be evaluated through additional diagnostic testing in selected patients. Treatment of pleurisy typically consists of pain management with nonsteroidal anti-inflammatory drugs, as well as specific treatments targeted at the underlying cause.     

Lung ultrasound in the evaluation of patients with pleuritic pain in the emergency department

The evaluation of pleuritic pain in the emergency setting is a diagnostic challenge. Most patients are discharged from the Emergency Department (ED) with a diagnosis of chest wall pain not otherwise specified. It is important to rule out possible sources of acute pleuritic pain, like pulmonary embolism, pneumonia, lung cancer, and pneumothorax. Clinical examination, plain film radiography of the chest, and other routine investigations may be inadequate to make the correct diagnosis. In this setting, another bedside test to aid diagnosis would be useful. ED bedside lung ultrasound is a novel technique for the diagnosis of lung diseases. We report on 5 patients who presented to our ED complaining of pleuritic pain, few other symptoms, and negative routine investigations, in whom bedside lung ultrasound aided in making the diagnosis.     

Diagnosing the cause of chest pain

Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. Risk of pulmonary embolism can be determined with a simple prediction rule, and a D-dimer assay can help determine whether further evaluation with helical computed tomography or venous ultrasound is needed. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. Chest pain also may be associated with panic disorder, for which patients can be screened with a two-item questionnaire. Clinical prediction rules can help clarify many of these diagnoses.     

Initial symptoms in pulmonary embolism differ from those in pneumonia: a retrospective study during seven years.

OBJECTIVE: To compare initial symptoms in pulmonary embolism with community-acquired pneumonia and relate to C-reactive protein and pulmonary infiltrates in order to improve the clinical assessment at the emergency department. METHODS: A retrospective review of patients with pulmonary embolism diagnosed in the clinic for infectious diseases (CID), (n=25), and a randomized sample of patients with pulmonary embolism diagnosed in the department of medicine (n=64), and a randomized sample of patients with community-acquired pneumonia (n=54) diagnosed in the clinic for infectious diseases. RESULTS: Initial symptoms in pulmonary embolism, dominated by dyspnoea and/or pleuritic chest pain were significantly different from those in community-acquired pneumonia, dominated by fever, chills and/or cough (P<0.001). On admission, C-reactive protein and body temperature were significantly higher and pulmonary infiltrates were more common in pneumonia compared with randomized pulmonary embolism patients. Twenty-five patients with a final diagnosis of pulmonary embolism were erroneously suspected of having lung infection, owing to increased C-reactive protein, presence of pulmonary infiltrates and/or high fever. However, they had classical symptoms of pulmonary embolism. CONCLUSIONS: Pulmonary infiltrates, high fever and a high level of C-reactive protein can deceive the physician to suspect pneumonia instead of pulmonary embolism. Classical initial symptoms ought to direct the physician in diagnosing pulmonary embolism. We emphasize a detailed patient history of initial symptoms.     

Recurrent pulmonary embolism originating from right atrial myxoma.

The use of transesophageal echocardiography is a useful adjunct to transthoracic echocardiography in the diagnosis and management of right atrial tumors in patients who are thought to have idiopathic recurrent pulmonary embolism, especially with suboptimal transthoracic echocardiography studies. We describe a 30-year-old woman with a history of recurrent pulmonary embolism who was admitted for investigation of pleuritic chest pain in whom transesophageal echocardiography played a critical role in the diagnosis and management.     

Pulmonary embolism in patients attending the accident and emergency department with pleuritic chest pain.

A series of 92 patients presenting to an accident and emergency department with pleuritic chest pain is described. Only one of the patients had a diagnosis of pulmonary embolus. All the patients were followed up over a period of 3 months. During this time none of them suffered from mortality or morbidity which could be related to pulmonary embolism. No evidence was obtained during this study that a more aggressive approach to such patients is required in order to achieve the diagnosis.     

Early recognition of pulmonary embolism: the key to lowering mortality

Pulmonary embolism is a major cause of morbidity and mortality in the United States. The majority of deaths from pulmonary embolism occur because an accurate diagnosis was not made. It is imperative for clinicians to have a high level of clinical suspicion of pulmonary embolism when patients present with dyspnea, tachypnea, chest pain, hemoptysis, and cough. If pulmonary embolism is diagnosed and treatment initiated, death and recurrence of embolism are uncommon. Beyond correct diagnosis and treatment, the single most effective strategy that can be employed to decrease the high mortality associated with pulmonary embolism is identification of individuals at risk and the institution of prophylactic measures. This article reviews the incidence, risk factors, assessment, physical examination, laboratory, and diagnostic testing for pulmonary embolism.     

Pulmonary embolization of 2-octyl cyanoacrylate after endoscopic injection therapy for gastric variceal bleeding

N-butyl-2-cyanoacrylate, a tissue adhesive that polymerizes on contact with weak bases such as blood, is being used widely outside the United States to obliterate gastric varices. Embolization of this material can occur via portosystemic shunts. We report a case of pulmonary embolization of 2-octyl cyanoacrylate (an analogue of N-butyl-2-cyanoacrylate) that occurred after endoscopic injection therapy for gastric variceal bleeding. Cyanoacrylate embolism is difficult to diagnose with computed tomographic angiography because radiopaque emboli are masked by the contrast material. It is important to distinguish these emboli from conventional thromboemboli because "glue emboli" require only symptomatic treatment. Clinicians should have a high index of suspicion for embolism in the setting of tachycardia, chest pain, or hypoxia after a patient undergoes endoscopic injection therapy with cyanoacrylate glue for gastric variceal bleeding. The radiologist should be alerted so that the appropriate radiographic settings are used to make the diagnosis.     

Patients with acute pulmonary embolism should have an echocardiogram to guide treatment decisions

A 62-year-old man with a past medical history notable for hypertension, osteoarthritis, and calf deep vein thrombosis at age 55 following a total hip arthroplasty presents to the emergency department with acute-onset dyspnea and right-sided pleuritic chest pains. His medications consist of a calcium channel blocker and a COX-2 inhibitor. Pretest clinical suspicion for pulmonary embolism (PE) is high. Ventilation and perfusion lung scintigraphy are interpreted as being high-probability for PE. The nurse asks if a stat transthoracic echocardiogram should be ordered.     

Chest pain

The accurate diagnosis of chest pain is often difficult. We review the differential diagnosis of chest pain and the diagnostic studies used in the evaluation of chest pain syndromes. Myocardial ischemia, aortic dissection, pulmonary embolism, pericarditis, and gastroenterologic sources of chest pain are the most common. The chest X-ray, electrocardiogram, echocardiogram, heart catheterization studies, and esophageal studies are helpful diagnostically.     

Diagnosis of radio-occult pulmonary conditions by real-time chest ultrasonography in patients with pleuritic pain

The evaluation of pleuritic pain in the emergency department (ED) presents a considerable challenge for the attending physician. Chest radiography (CXR) is a basic test, but its sensitivity is low, and often more sophisticated imaging techniques are needed. Our aim is to assess the diagnostic value of bedside B-mode lung ultrasound (LUS) in the visualization of radio-occult pulmonary lesions. Forty-nine patients complaining of pleuritic pain with negative CXR were prospectively studied by LUS. Detection of at least one of the following sonographic signs in the painful thoracic area was considered diagnostic: (i) the absence of pleural sliding; (ii) the focal alveolar-interstitial syndrome (AIS), defined by multiple artifacts B-line; (iii) the peripheral alveolar consolidation (PAC), defined by hypoechoic subpleural images; and (iv) the pleural disruption with thickening and irregularity of the line, with or without localized effusion. The final diagnoses were confirmed by spiral CT scanning (n = 12) and follow-up (n = 37). Final diagnoses were chest wall pain (n = 30), pleuropneumonia (n = 14), pulmonary embolism (n = 4), lung metastasis (n = 1). In 18 patients of the group with pulmonary conditions, LUS showed signs of pleurisy. They were PAC (n = 12), AIS (n = 17), pleural disruption (n = 17). If any sign is considered, the sensitivity of LUS in the diagnosis of radio-occult lesions was 94.7%, specificity was 96.7%, positive and negative predictive values were 94.7% and 96.7%, respectively, and accuracy was 95.9%. In patients with pleuritic pain of unknown cause, real-time LUS enables the diagnosis of radio-occult lung and pleural lesions.     

Computed tomography to assess possible cardiac lead perforation

BACKGROUND: Chest radiography and echocardiography are standard techniques to evaluate possible extracardiac migration of pacemaker and defibrillator leads, but computed tomography (CT) scanning may be a helpful adjunct. METHODS: Chest CT using a 64-detector helical scanner was performed in three cases of lead perforation where standard techniques did not yield a definitive diagnosis. In two patients, a cardiac CT protocol was followed, the primary indication for which was to assess the lead tip location. On one patient, persistent chest pain several days after the implant led to a chest CT to rule out a pulmonary embolism, and the extracardiac lead was found fortuitously. RESULTS: In all cases, CT scan images resulted in a definitive diagnosis of extracardiac migration of pacemaker or defibrillator leads. One patient had an extracardiac atrial lead which was dysfunctional but not associated with symptoms. The risks of repositioning were felt to outweigh potential benefits in this patient with chronic obstructive pulmonary disease, and treatment was conservative. The other two patients had extracardiac ventricular leads and were symptomatic with pleuritic chest pain. These patients were treated by lead revision with no evidence of bleeding into the pericardial space. All patients did well and none have suffered any further complications. CONCLUSION: CT images aid in the diagnosis of lead perforation when other modalities are nondiagnostic. Recent advances in CT technology have been associated with increased use of this technique for evaluation of chest pain, analysis of which should now include location of intracardiac leads.     

A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED

Purposes

Bedside lung ultrasound (LUS) is useful in detecting radio-occult pleural-pulmonary lesions. The aim of our study is to compare the value of LUS with other conventional routine diagnostic tools in the emergency department (ED) evaluation of patients with pleuritic pain and silent chest radiography (CXR).

Methods

Ninety patients consecutively admitted to the ED with pleuritic pain and normal CXR were retrospectively (n = 49) and prospectively (n = 41) studied. All patients were blindly examined by LUS and submitted to clinical examination and blood samples. The ability of blood tests and symptoms to predict any radio-occult pleural-pulmonary condition confirmed by conclusive image techniques and follow-up was evaluated and compared with LUS.

Results

In 57 cases, the final diagnosis was chest wall pain. The other 33 patients were diagnosed with a pleural-pulmonary condition (22 pneumonia, 2 pleuritis, 7 pulmonary embolism, 1 lung cancer, 1 pneumothorax). Lung ultrasound showed a sensitivity of 96.97% (95% confidence interval [CI], 84.68%-99.46%) and a specificity of 96.49% (95% CI, 88.08%-99.03%) in predicting radio-occult pleural-pulmonary lesions and significantly higher area under the curve (AUC) of receiver operating characteristic analysis (AUC, 0.967; 95% CI, 0.929-1.00) than d-dimer (AUC, 0.815; 95% CI, 0.720-0.911) and white blood cell count (AUC, 0.778; 95% CI, 0.678-0.858). None of the other routine tests considered or a combination between them better predicted the final diagnosis.

Conclusions

Chest radiography and blood tests may be inadequate in the diagnostic process of pleuritic pain. In case of silent CXR, LUS is critical for identifying patients with pleural-pulmonary radio-occult conditions at bedside and cannot be safely replaced by other conventional methods.     

An Emergency Department Guideline for the Diagnosis of Pulmonary Embolism: An Outcome Study

OBJECTIVE: To assess the clinical outcome of patients suspected of pulmonary embolism (PE) following implementation of an emergency department (ED) diagnostic guideline. METHODS: A prospective observational study of all patients suspected of PE who presented to the ED during a four-month study period. The authors' modification of the Charlotte criteria recommended D-dimer testing in those younger than 70 years of age with a low clinical suspicion of PE and no unexplained hypoxemia, unilateral leg swelling, recent surgery, hemoptysis, pregnancy, or prolonged duration of symptoms. The primary outcome was the identification of venous thromboembolism during a three-month follow-up period. The negative predictive value of the overall diagnostic strategy and the test characteristics of D-dimer were calculated. RESULTS: A total of 1,207 consecutive patients were evaluated for suspected PE; 71 (5.8%) were diagnosed with venous thromboembolism. One missed case of PE was identified on follow-up, yielding a negative predictive value of 99.9% (95% confidence interval [CI] = 99.5% to 100%). The missed case was a patient who presented with pleuritic chest pain and shortness of breath; a chest radiograph revealed pneumothorax, and the physician decided not to pursue the positive D-dimer result. The patient returned six weeks later with PE. Subgroup analysis of patients having D-dimer performed (n = 677) yields a sensitivity of 0.93 (95% CI = 0.77 to 0.98) and a specificity of 0.74 (95% CI = 0.70 to 0.77). CONCLUSIONS: Implementation of a PE diagnostic guideline in a community ED setting is safe and has improved the specificity of the enzyme-linked immunosorbent assay D-dimer test when compared with previous studies.     

Boerhaave's syndrome: an elusive diagnosis

Boerhaave's syndrome represents a diagnostic dilemma for the emergency physician. The prognosis of this truly life-threatening emergency is darkened by any significant diagnostic delay. Unfortunately, classic or expected symptoms and signs are frequently absent at presentation, a circumstance that leads to frequent misdiagnosis. Two cases of Boerhaave's syndrome with "atypical" clinical presentations are reviewed and discussed. It is clear that Boerhaave's syndrome should always be suspected in the evaluation of any sudden chest, abdominal, or back pain associated with emesis. However, emphasis should be placed on the fact that this entity may occur without emesis. The chest radiograph is the most helpful diagnostic aid. Undoubtedly, maintenance of a high degree of suspicion by the emergency physician for Boerhaave's syndrome will lead consistently to earlier diagnosis, and subsequent aggressive intervention should result in considerable reduction in rates of both morbidity and mortality.     

Case report: aortic dissection and cystic medial degeneration in a 24-year-old without Marfan syndrome

The effective management of aortic dissection relies heavily on a high index of suspicion followed by timely definitive diagnosis. Young adults without a history of blunt trauma who are not at risk for atherosclerotic disease may lower this suspicion. We present a 24-year-old patient with complaints of chest pain who presented in multiple urgent care clinics and emergency departments. With a normal chest radiograph, he was repeatedly discharged home on analgesics until a loud murmur was heard. An echocardiogram revealed a dilated aortic root with an intimal flap consistent with a type II dissection. After surgical aortic repair with a Bentall procedure, he was discharged with complete relief of symptoms. Histologic reports revealed cystic medial degeneration. Physical examinations did not demonstrate the phenotypic manifestations of Marfan syndrome. This case illustrates the importance of cardiac auscultation when assessing an individual with chest pain, even with a low likelihood for alteration in arterial structure, and the maintenance of a high index of clinical suspicion despite a normal chest radiograph. We consider this case to be of interest because of its rarity in a 24-year-old.     

肺栓塞的诊断方法

肺栓塞在临床上较为常见,但诊断较困难。诊断应始于识别肺栓塞发生的危险因素及评估患者发生肺栓塞的可能性大小以及患者的临床症状和体征。常规的客观检查包括D-二聚体测定、心电图、胸片及超声心动图等。近年来,尚有人研究经食道超声在肺栓塞诊断中的价值。而且,随着影像学技术的发展,CT血管造影(CTA)、磁共振血管造影(MRA)及与其相关的一系列先进手段也逐渐应用于肺栓塞的诊断中,并显示出良好的应用前景。肺血管造影一直被认为是肺栓塞诊断的金标准,有人认为,多探测器螺旋CT(MDCT)的运用可能成为诊断肺栓塞的无创金标准,但结合临床的综合判断仍是诊断的基础。     

Coronary CT angiography in emergency department patients with acute chest pain: triple rule-out protocol versus dedicated coronary CT angiography

Immediate coronary catheterization is mandatory for high risk patients with typical chest pain in the emergency department (ED). In contrast, in ED patients with acute chest pain but low to intermediate risk, traditional management protocol includes serial ECG, cardiac troponins and radionuclide perfusion imaging. However, this protocol is time-consuming and expensive, and definite treatment of unstable angina is often delayed. Due to advances of multi-detector CT (MDCT) technology, dedicated coronary CT angiography provides the potential to rapidly and reliably diagnose or exclude acute coronary syndrome in ED patients with acute chest pain. Moreover, major life-threatening causes of ED chest pain (i.e., acute aortic syndrome and pulmonary embolism as well as acute coronary syndrome) can simultaneously be assessed by the so-called “triple rule-out” protocol with a single scan. In ED patients with atypical chest pain and low to intermediate risk, the triple rule-out protocol may be preferred, especially in older patients who have relatively lower risk of lifelong radiation-induced cancer. However, the increased radiation dose resulting from the extended volume coverage with this protocol should be fully considered prior to performing this protocol. Therefore, in ED patients who have a low clinical suspicion of pulmonary embolism and acute aortic syndrome, especially younger patients, dedicated coronary CT angiography accompanied by modifications to reduce radiation dose is recommended.     

胸痛相关肺血管病的诊治进展

胸痛是临床常见症状之一,本文针对以胸痛特点为临床表现的肺血管疾病进展予以综述,尤其是致死性肺栓塞的危险因素、临床表现、诊疗及预防等方面的进展,提高对肺栓塞的认识水平,为临床肺血管病的诊治提供参考,并提出了围绕肺血管病的诊治管理模式。     

Thoracic aortic pseudoaneurysm following noncardiovascular surgery: a rare complication that can mimic common chest emergencies

Pseudoaneurysm of the thoracic aorta is an extremely rare and potentially fatal condition that can mimic acute coronary syndrome, aortic dissection, or pulmonary embolism. Chest trauma and aortic surgery are the usual predisposing factors. Rarely, noncardiovascular thoracic surgeries can result in aortic pseudoaneurysm secondary to unrecognized perioperative injury. Clinical presentation is very variable, and a high index of suspicion is necessary for diagnosis. Computed tomography or magnetic resonance angiography is the preferred diagnostic test. In this paper, we report the case of a 58-year-old woman who presented with atypical chest pain due to a thoracic aortic pseudoaneurysm, most likely a result of previous nonvascular surgery.