eMedicine Specialties > Pulmonology > Pleural Disorders

Pleurodynia: Differential Diagnoses & Workup

Author: Irina Petrache, MD, Associate Professor of Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Occupational Medicine, Indiana University
Coauthor(s): Ninotchka Liban Sigua, MD, Fellow, Department of Pulmonary and Critical Care, Indiana University
Contributor Information and Disclosures

Updated: Apr 17, 2009

Differential Diagnoses

Aortic Dissection
Pneumothorax
Asthma
Pulmonary Embolism
Herpes Zoster
Pulmonary Hypertension, Primary
Mediastinitis
Sarcoidosis
Mediterranean Fever, Familial
Systemic Lupus Erythematosus
Mesothelioma
Tuberculosis
Pancreatitis, Acute
Pneumonia, Bacterial
Pneumonia, Viral

Other Problems to Be Considered

Pleurisy, viral or idiopathic
Sickle cell crisis
Fractured rib
Mediastinal emphysema
Other tumors of the pleural space, soft tissue sarcoma
Bronchiolitis obliterans with organizing pneumonia (BOOP)
Intercostal neuralgia
Hyperventilation syndrome
Myositis4
Drug-induced myalgias: Esomeprazole has been involved in a case report of myalgia, cephalgia, and fever.5

Workup

Laboratory Studies

Coxsackie B virus infection can be diagnosed by isolation of the virus in cell culture, detection of virus RNA via polymerase chain reaction (PCR) or serologic evaluation of viral antibodies.6

  • Viral cultures
    • Primary monkey kidney cells or embryonic lung fibroblasts are the standard cells used for isolation and identification of coxsackievirus B. The addition of Buffalo green monkey kidney cells may increase the sensitivity of this method. Viral growth occurs in 1-4 days, causing a cytopathic effect on the host cells, resulting in rounded, refractile cells that eventually lyse. The cultures may be performed from various clinical specimens, dictated by the presence of clinical symptoms.
    • Throat viral cultures are more sensitive than urine viral cultures and confirm 33% of the enteroviral infections studied. Throat culture findings were positive for coxsackievirus B in 45% of the patients presenting with pleurodynia. Blood cultures are useful in children younger than 3 months. Stool cultures have a higher yield than rectal swabs. Having multiple culture specimens may also increase the yield of virus recovery in culture.
    • A positive enteroviral culture result must be interpreted in light of the clinical context and the history of polio immunization. After vaccination with the live attenuated oral polio vaccine, viral culture results from both throat and stool specimens may remain positive for enteroviruses for several months. Similarly, patients with asymptomatic infections may shed the virus for months after they acquire the infection.
    • Cerebrospinal fluid (CSF) viral cultures have limited clinical utility in the management of enteroviral meningitis due to poor sensitivity (65-75%), high cost, and long turnaround time.
  • Fluorescent staining and neutralization assays: Using specific antibodies, these tests are used to further confirm and delineate the type of enterovirus isolated from cell culture.
  • Molecular diagnosis
    • Reverse transcriptase PCR (RT-PCR) has gained wide acceptance for the detection of viral nucleic acids, especially from specimens with a low viral load that may be associated with false-negative cell culture results.7 In the CSF, RT-PCR has better sensitivity than viral culture. In children, RT-PCR for throat specimens was also more sensitive than viral culture. Another advantage is the rapid turnaround time, which has resulted to improved health care costs, especially in the management of enteroviral meningitis.8,9
    • Commercial diagnostic RT-PCR kits are available for the identification of coxsackievirus B RNA.
    • One disadvantage of RT-PCR is that the virus serotype cannot be identified. Additional restriction fragment length polymorphism (RFLP) assays may provide a simple strategy to identify the virus subtype.10
  • Serologic studies for viral antigen detection: Specific antibodies against enteroviral groups and serotypes are commercially available, but their application has thus far been limited to fluorescent staining and detection of viral antigens in cell cultures, rather than clinical specimens.
    • Enzyme-linked immunosorbent assay (ELISA) is more sensitive than the neutralization test and can be used as a screening tool, followed by the neutralization test for confirmation.
    • ELISA using an enteroviruses group–specific monoclonal antibody may detect early immunoglobulin M (IgM) antibody secreted during coxsackievirus B infection. The test is more sensitive than the neutralization tests and can be used as a screening tool, followed by the neutralization test. The specificity is not extremely high because the antibodies cross-react with other enteroviruses such as hepatitis A virus.11,12
    • The neutralization assay measures the ability of the serum to antagonize the viral infectivity in cell culture. Although the test is expensive and awkward, a more specific finding of a positive ELISA result followed by a negative neutralization test result usually signifies an enteroviral infection other than that caused by coxsackievirus B.
  • Complement fixation test: This test is another laborious method of measuring antiviral antibodies used to diagnose coxsackievirus B infection.
  • Other tests and findings
    • Serum creatine kinase is usually elevated because of muscle necrosis.
    • The white cell count ranges from mild leukopenia to mild leukocytosis.
    • Although seldom performed for the diagnosis of pleurodynia per se, tissue diagnosis can be made by direct detection of the viral antigen or by isolation of RNA virus-specific sequences.
    • Depending on the clinical presentation and suspicion for serositis caused by systemic lupus erythematosus, an antinuclear antibody test can be performed.

Imaging Studies

  • Chest radiography
    • A chest radiograph is usually obtained to exclude other causes of chest pain. In pleurodynia, the findings on chest radiography can be normal, or the radiograph may show a small amount of ipsilateral pleural effusion or adjacent atelectasis from splinting.
    • The atelectasis can be linear or in the form of bibasilar consolidation.
    • Infrequently, the coxsackievirus B infection causes pneumonia, with a radiographic pattern of fine perihilar opacities.

Histologic Findings

Necrosis of the striated intercostal muscles is visible. Rarely, adjacent pleural inflammation results in a small exudative pleural effusion.

More on Pleurodynia

Overview: Pleurodynia
Differential Diagnoses & Workup: Pleurodynia
Treatment & Medication: Pleurodynia
Follow-up: Pleurodynia
References
[ CLOSE WINDOW ]

References

  1. Bell EJ, Grist NR. ECHO viruses, carditis, and acute pleurodynia. Am Heart J. Jul 1971;82(1):133-5. [Medline].

  2. Moore M, Kaplan MH, McPhee J, Bregman DJ, Klein SW. Epidemiologic, clinical, and laboratory features of Coxsackie B1-B5 infections in the United States, 1970-79. Public Health Rep. Sep-Oct 1984;99(5):515-22. [Medline].

  3. Kaplan MH, Klein SW, McPhee J, Harper RG. Group B coxsackievirus infections in infants younger than three months of age: a serious childhood illness. Rev Infect Dis. Nov-Dec 1983;5(6):1019-32. [Medline].

  4. Crum-Cianflone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev. Jul 2008;21(3):473-94. [Medline].

  5. Grattagliano I, Portincasa P, Mastronardi M, Palmieri VO, Palasciano G. Esomeprazole-induced central fever with severe myalgia. Ann Pharmacother. Apr 2005;39(4):757-60. [Medline].

  6. Rotbart HA, Sawyer MH, Fast S, Lewinski C, Murphy N, Keyser EF, et al. Diagnosis of enteroviral meningitis by using PCR with a colorimetric microwell detection assay. J Clin Microbiol. Oct 1994;32(10):2590-2. [Medline].

  7. Romero JR. Reverse-transcription polymerase chain reaction detection of the enteroviruses. Arch Pathol Lab Med. Dec 1999;123(12):1161-9. [Medline].

  8. Nolte FS. Case studies in cost effectiveness of molecular diagnostics for infectious diseases: pulmonary tuberculosis, enteroviral meningitis, and BK virus nephropathy. Clin Infect Dis. Dec 1 2006;43(11):1463-7. [Medline].

  9. Noordhoek GT, Weel JF, Poelstra E, Hooghiemstra M, Brandenburg AH. Clinical validation of a new real-time PCR assay for detection of enteroviruses and parechoviruses, and implications for diagnostic procedures. J Clin Virol. Feb 2008;41(2):75-80. [Medline].

  10. Patel DD, Kapoor A, Ayyagari A, Dhole TN. Development of a simple restriction fragment length polymorphism assay for subtyping of coxsackie B viruses. J Virol Methods. Sep 15 2004;120(2):167-72. [Medline].

  11. Goldwater PN. Immunoglobulin M capture immunoassay in investigation of coxsackievirus B5 and B6 outbreaks in South Australia. J Clin Microbiol. Jun 1995;33(6):1628-31. [Medline].

  12. McCartney RA, Banatvala JE, Bell EJ. Routine use of mu-antibody-capture ELISA for the serological diagnosis of Coxsackie B virus infections. J Med Virol. Jul 1986;19(3):205-12. [Medline].

  13. McEvoy GK. Nonsteroidal Anti-inflammatory Agents. In: AHFS Drug information. Bethesda, Md: American Society of Health-System Pharmacists; 2000.

  14. Ikeda RM, Kondracki SF, Drabkin PD, Birkhead GS, Morse DL. Pleurodynia among football players at a high school. An outbreak associated with coxsackievirus B1. JAMA. Nov 10 1993;270(18):2205-6. [Medline].

  15. Druce JD, Russell JS, Birch CJ, Vickery K, Harper RW, Smolich JJ. Cleaning and sterilization protocol for reused cardiac electrophysiology catheters inactivates hepatitis and coxsackie viruses. Infect Control Hosp Epidemiol. Aug 2005;26(8):720-5. [Medline].

  16. Bell EJ, McCartney RA, Riding MH. Coxsackie B viruses and myalgic encephalomyelitis. J R Soc Med. Jun 1988;81(6):329-31. [Medline].

  17. Dussart P, Cartet G, Huguet P, Lévêque N, Hajjar C, Morvan J, et al. Outbreak of acute hemorrhagic conjunctivitis in French Guiana and West Indies caused by coxsackievirus A24 variant: phylogenetic analysis reveals Asian import. J Med Virol. Apr 2005;75(4):559-65. [Medline].

  18. Huber S, Ramsingh AI. Coxsackievirus-induced pancreatitis. Viral Immunol. 2004;17(3):358-69. [Medline].

  19. Spotnitz MD, Lesch M. Idiopathic dilated cardiomyopathy as a late complication of healed viral (Coxsackie B virus) myocarditis: historical analysis, review of the literature, and a postulated unifying hypothesis. Prog Cardiovasc Dis. Jul-Aug 2006;49(1):42-57. [Medline].

  20. Thomas L, Reichl M. Pulmonary embolism in patients attending the accident and emergency department with pleuritic chest pain. Arch Emerg Med. Mar 1991;8(1):48-51. [Medline].

  21. Ornoy A, Tenenbaum A. Pregnancy outcome following infections by coxsackie, echo, measles, mumps, hepatitis, polio and encephalitis viruses. Reprod Toxicol. May 2006;21(4):446-57. [Medline].

  22. Branch WT Jr, McNeil BJ. Analysis of the differential diagnosis and assessment of pleuritic chest pain in young adults. Am J Med. Oct 1983;75(4):671-9. [Medline].

  23. Dagan R, Jenista JA, Prather SL, Powell KR, Menegus MA. Viremia in hospitalized children with enterovirus infections. J Pediatr. Mar 1985;106(3):397-401. [Medline].

  24. Disney ME, Howard EM, Wood BS, Findlay GM. Bornholm disease in children. Br Med J. Jun 20 1953;1(4824):1351-4. [Medline].

  25. Fraser RG, Pare JA. Coxsackievirus respiratory infection. Diag Dis Chest. 1978;2:834-35.

  26. Lau RC. Coxsackie B virus infections in New Zealand patients with cardiac and non-cardiac diseases. J Med Virol. 1983;11(2):131-7. [Medline].

  27. Mintz L, Drew WL. Relation of culture site to the recovery of nonpolio enteroviruses. Am J Clin Pathol. Sep 1980;74(3):324-6. [Medline].

  28. Murray BJ. Complications following coxsackievirus B infection. Am Fam Physician. Nov 1988;38(5):115-8. [Medline].

  29. Pichichero ME, McLinn S, Rotbart HA, Menegus MA, Cascino M, Reidenberg BE. Clinical and economic impact of enterovirus illness in private pediatric practice. Pediatrics. Nov 1998;102(5):1126-34. [Medline].

  30. Roth B, Enders M, Arents A, Pfitzner A, Terletskaia-Ladwig E. Epidemiologic aspects and laboratory features of enterovirus infections in Western Germany, 2000-2005. J Med Virol. Jul 2007;79(7):956-62. [Medline].

  31. Storch GA. Essentials of Diagnostic Virology. New York, NY: Churchill Livingstone; 2000.

  32. Swanink CM, Veenstra L, Poort YA. Coxsackievirus B1-based antibody-capture enzyme-linked immunosorbent assay for detection of immunoglobulin G (IgG), IgM, and IgA with broad specificity for enteroviruses. J Clin Microbiol. Dec 1993;31(12):3240-6. [Medline].

  33. Wilson PM, Kusumakar V, McCartney RA, Bell EJ. Features of Coxsackie B virus (CBV) infection in children with prolonged physical and psychological morbidity. J Psychosom Res. 1989;33(1):29-36. [Medline].

  34. Yagi S, Schnurr D, Lin J. Spectrum of monoclonal antibodies to coxsackievirus B-3 includes type- and group-specific antibodies. J Clin Microbiol. Sep 1992;30(9):2498-501. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

pleurodynia, pleuritis, pleuritic pain, lancinating chest pain, costalgia, epidemic pleurodynia, Bornholm disease, Bornholm's disease, Devil grip, Devil's grip, epidemic myalgia, coxsackievirus B, enteroviruses, meningitis, carditis, Sylvest's disease, Sylvest disease, epidemic benign dry pleurisy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Irina Petrache, MD, Associate Professor of Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Occupational Medicine, Indiana University
Irina Petrache, MD is a member of the following medical societies: American Thoracic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Ninotchka Liban Sigua, MD, Fellow, Department of Pulmonary and Critical Care, Indiana University
Ninotchka Liban Sigua, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

Helen M Hollingsworth, MD, Director, Adult Asthma and Allergy Services, Associate Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, Boston Medical Center
Helen M Hollingsworth, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American Thoracic Society, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gregg T Anders, DO, Medical Director, Great Plains Regional Medical Command , Brook Army Medical Center; Clinical Associate Professor, Department of Internal Medicine, Division of Pulmonary Disease, University of Texas Health Science Center at San Antonio
Gregg T Anders, DO is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.