eMedicine Specialties > Pulmonology > Pleural Disorders

Pleurodynia

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

Introduction

Background

Pleurodynia is an uncommon complication of coxsackievirus B infection and is defined as the sudden occurrence of lancinating chest pain or abdominal pain attacks, commonly associated with fever, malaise, and headaches. Coxsackievirus B is an RNA Enterovirus, which usually causes an asymptomatic or brief upper respiratory tract or gastroenteric infection. In rare cases, other severe sequelae of coxsackievirus B infection develop, including meningitis and carditis.1

Also see the eMedicine article Coxsackieviruses.

Pathophysiology

The striated muscle is the actual anatomic structure targeted by the coxsackievirus B and is responsible for the attacks of severe chest pain. Therefore, the term pleurodynia may be a misnomer because only some patients with the condition actually develop pleuritis (ie, inflammation of the pleural surface). In patients with pleurodynia, the striated intercostal muscles necrose, which explains the frequent elevations in serum creatine kinase levels. Some of the more chronic sequelae, such as myocarditis, dermato-polymyositis, chronic fatigue syndrome, and possibly, juvenile-onset diabetes type I, are believed to be immune mediated.

The virus has an incubation time of 1 week in the gastrointestinal tract and then, through hematogenous dissemination, involves the target organs, most commonly the skeletal muscles but also the CNS (ie, meningitis, encephalitis) and myocardium (ie, carditis with or without associated pericarditis). Coxsackievirus B can be recovered in the stool or pharynx for up to 2 weeks after the resolution of the symptoms.

Frequency

United States

Coxsackievirus B was present in 24% of the 18,000 enteroviruses isolated and reported in the United States from 1970-1979.2 The estimated number of nonpolio enteroviral symptomatic infections is 5-10 million per year.

In regions of temperate climate, the infection is seasonal, with about 90% of infections occurring in the summer and early fall, and sometimes infections occur in epidemics.

The incidence of coxsackievirus B infection in neonates is 1 in 2000 live births.

International

Antibodies to coxsackievirus B serotypes are present in 75% of the population in developed countries. In the tropical and subtropical climate areas, the prevalence of the enteroviral infections is year-round.

Mortality/Morbidity

The severity of the coxsackievirus B infection is highest in infants and children. In infants who develop coxsackievirus B infection, 10% die, usually within the first 4 weeks of life most commonly from cardiac involvement. Fulminant hepatic failure, sepsis syndrome, and severe CNS involvement with seizures and apnea are also potential complications in this age group.3

Sex

Males are more commonly affected than females.

Age

Coxsackievirus B infection occurs most commonly in children younger than 15 years; half of these patients are younger than 5 years, and 30% are younger than 1 year. The disease is rare in patients older than 60 years. However, pleurodynia most commonly affects adults infected with the virus, with fewer than 10% of cases occurring in patients younger than 20 years. Of the 372 prospectively studied children aged 4-18 years with nonpolio enteroviral infections, only 3% developed pleurodynia. In contrast, 30 of the 78 mostly adult patients with coxsackievirus B-associated cardiac disease had pleurodynia. Therefore, the location of pain is believed to be predominantly thoracic in adults and abdominal in children.

Clinical

History

The onset of chest pain is acute. During attacks, the pain is severe, intense, and excruciating, lasting seconds to a minute. Pain is paroxysmal, occurring in attacks separated by minutes to hours. Severe attacks can result in difficulty breathing. The thoracic pain is usually over the lower ribs and is unilateral, but it can also occur over the front, back, or substernal area. Between attacks, patients usually have a constant, dull, pleuritic chest pain. The attacks usually persist for 3-5 days and rarely last longer than a month and may go through phases of remission and exacerbation.

  • Associated symptoms related to the viral infection may include the following:
    • Upper respiratory tract symptoms, including sore throat, rhinitis, and dry cough
    • Constitutional symptoms, including headaches (50%), fever, and malaise
    • GI symptoms, including nausea, vomiting, diarrhea (50%); abdominal pain (usually in the epigastric area) in children
    • Testicular pain (ie, orchitis) in 10% of males

Physical

  • Fever (97%) and appropriate heart rate response (ie, tachycardia)
  • Respiratory system findings - Pharyngitis (85%), including herpangina, visible splinting of the chest during attacks, localized chest wall tenderness in the same area of pain (25%), and pleural friction rub (25%)
  • Other potential signs associated with the coxsackievirus B infection - Otitis (25%) and dermatitis (30%)

Causes

  • The classic etiologic agent for pleurodynia is coxsackievirus B, serotypes B1, B2, B3, B4, and B5, which are small, nonenveloped RNA viruses, in which an icosahedral capsid encloses the single-stranded RNA genome.
  • Other nonpolio enteroviruses, including echoviruses type 6 and 19 and coxsackievirus A, are also reported to cause syndromes very similar to that of coxsackievirus B infection, including pleurodynia.
  • Humans are the only known reservoir of the enteroviruses; transmission occurs via the fecal-oral route. The incubation time is usually  2-5 days. Potential risk factors for the transmission of the enteroviruses are poor sanitation and overcrowding. Intrafamilial spread is common.

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.

RELATED MEDSCAPE ARTICLES
Articles
 
 
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.