Dry (fibrinous) pleurisy - Diagnosis

Laboratory diagnostics of dry pleurisy

1. Complete blood count: possible increase in ESR, leukocytosis and shift in the leukocyte formula to the left (not a constant sign).
2. General urine analysis - no pathological changes.
3. Biochemical blood test - possible increase in the content of seromucoid, fibrin, sialic acids, alpha2-globulin.

Instrumental diagnostics of dry pleurisy

X-ray examination of the lungs

In fibrinous pleurisy, a high position of the diaphragm dome on the corresponding side, its lag during deep breathing, limited mobility of the lower pulmonary edge, and slight opacity of part of the pulmonary field can be determined. With significant fibrin deposits, it is sometimes possible to determine an unclear, indistinct shadow along the outer edge of the lung (a rare sign).

Ultrasound examination

Ultrasound examination can reveal intense fibrin deposits on the parietal or visceral pleura. They look like thickening of the pleura with an uneven, wavy contour, increased echogenicity, and a homogeneous structure.

Differential diagnosis of dry (fibrinous) pleurisy

[ 1 ], [ 2 ]

Intercostal neuralgia

The differences between dry pleurisy and intercostal neuralgia (intercostal neuromyositis) are presented in the table.

Bornholm disease

Bornholm disease (epidemic myalgia) is caused by enteroviruses (most often Coxsackie B). Epidemic outbreaks of the disease are most often observed in the summer-autumn period, individual cases of the disease can develop at any time of the year. Children and young people are most often ill. The disease begins with fever, rhinitis, sore throat when swallowing. Pain in the chest or upper abdomen is characteristic, it intensifies with breathing, movement and is accompanied by significant tension in the intercostal muscles. Along with this, patients hear pleural friction noise, which indicates the involvement of the pleura in the inflammatory process. Usually, the disease proceeds favorably and ends in recovery in 7-10 days. In some cases, damage to the heart and central nervous system is possible.

Differential diagnostic differences between dry pleurisy, intercostal neuralgia, intercostal neuromyositis

Signs	Dry pleurisy	Intercostal neuralgia, intercostal neuromyositis
Conditions of occurrence in the chest	Pain associated with breathing, coughing	The pain is associated with movements, bending of the body, excessive physical exertion
Relationship between pain and torso tilt	The pain intensifies when bending the body towards the healthy side (due to stretching of the inflamed pleura)	The pain intensifies when bending the body towards the painful side
Palpation of the intercostal spaces	Causes moderate pain in the area where pleural friction rub is heard	Causes acute intense pain, especially in the areas where the intercostal nerve and its branches are closest to the surface of the chest: at the spine, at the level of the midaxillary line and at the sternum
Pleural friction rub	It is heard in the area corresponding to the deposition of fibrin on the pleural sheets.	Absent
Increased ESR	It happens often	Not typical
Increased body temperature	It happens often	Not typical

The diagnosis of Bornholm disease is based on typical clinical manifestations, multiple cases of the disease in the summer-autumn season, virus isolation from the pharynx and high titers of antiviral antibodies in the blood serum. These same signs allow to differentiate Bornholm disease from dry pleurisy.

Differential diagnostic differences between left-sided paramediastinal pleurisy and fibrinous pericarditis

Signs	Left-sided paramediastinal dry pleurisy	Fibrinous pericarditis
Localization of pain	Mainly on the left edge of the relative cardiac dullness	Mainly in the precordial region
Increased pain when breathing and coughing	Typical	Maybe, but less typical
Localization of friction noise	Pleural friction rub or pleuropericardial rub is more clearly defined at the left edge of the relative cardiac dullness	Pericardial friction rub is heard in the area of absolute cardiac dullness and is not conducted anywhere
Dependence of friction noise on the breathing phase	Pleuropericardial murmur increases at the height of inspiration, weakens during expiration and persists when holding the breath	Pericardial friction rub is heard constantly, regardless of the breathing phases
Synchronicity of friction noise with cardiac activity	Pleural friction rub is asynchronous with cardiac activity, pleuropericardial rub is synchronous with cardiac activity	Constant synchronous connection of pericardial friction noise with cardiac activity

[ 3 ], [ 4 ], [ 5 ], [ 6 ]

Pericarditis

The presence of pain in the left half of the chest, often radiating to the precordial region, requires differential diagnosis of left-sided paramediastinal dry pleurisy and fibrinous pericarditis.

Angina pectoris

Left-sided fibrinous pleurisy must be differentiated from angina pectoris due to some similarity of pain syndrome, especially with paramediastinal localization of dry pleurisy.

Differential diagnostic differences between left-sided paramediastinal pleurisy and angina pectoris

Signs	Left-sided paramediastinal dry pleurisy	Angina pectoris
Localization of pain	Mainly on the left edge of the relative cardiac dullness	Retrosternal
Conditions for the occurrence of pain	The pain intensifies with deep breathing and coughing.	The pain appears and intensifies with physical activity, walking, and climbing stairs.
Pain irradiation	Not typical	Characteristic of the left arm, left shoulder, shoulder blade
Pleural friction rub	Characteristic, often audible pleuropericardial noise	Not typical
The relieving effect of nitroglycerin	Absent	Very characteristic
ECG	No significant changes	Ischemic changes

[ 7 ], [ 8 ], [ 9 ], [ 10 ], [ 11 ], [ 12 ]

Myocardial infarction

Differential diagnostic differences between paramediastinal pleurisy and myocardial infarction are presented in the table.

Acute appendicitis

Diaphragmatic pleurisy manifests itself as pain mainly in the upper parts of the right half of the abdomen, however, the pain often radiates to the right iliac region and "simulates" appendicitis. The following symptoms are characteristic of appendicitis:

• Shchetkin-Blumberg symptom (the appearance of pain when the hand immersed in the abdominal cavity is suddenly removed)
• Rovsing's symptom (appearance or increase of pain in the right iliac region when pressing or gently pushing with the palm of the hand in the left iliac region)
• Sitkovsky's symptom (increased pain in the right iliac region when the patient is lying on the left side, which is caused by tension in the mesentery of the inflamed cecum)
• Bartamier-Michelson symptom (increased pain upon palpation of the right iliac region with the patient lying on the left side)
• Obraztsov's symptom (increased pain in the right iliac region if you lightly press on the abdominal wall and force the patient to lift the straightened right leg

[ 13 ], [ 14 ], [ 15 ]

Gastric ulcer and duodenal ulcer

When performing differential diagnostics of diaphragmatic pleurisy and gastric ulcer and duodenal ulcer, it should be taken into account that gastric ulcer is characterized by pain associated with food intake (0.5-1 hour after eating for gastric ulcer, 1.5-2 hours after eating and on an empty stomach for duodenal ulcer); heartburn; sour belching; vomiting that brings relief; positive Mendel's symptom - local percussion pain corresponding to the ulcer localization. The diagnosis is easily verified using fibrogastroscopy. Diaphragmatic pleurisy is not characterized by pain associated with food intake; there are no "hunger" pains.

Spontaneous pneumothorax

The need for differential diagnosis of these diseases is explained by the fact that a characteristic symptom of both diseases is intense pain in the chest.

Differential diagnostic differences between fibrinous pleurisy and spontaneous pneumothorax

Signs	Fibrinous pleurisy	Spontaneous pneumothorax
Circumstances preceding the development of the disease	Often infectious and inflammatory diseases of the upper respiratory tract, pneumonia	Intense physical activity, coughing, sudden movements
Characteristics of pain	Sudden intense pain in the chest, increasing with breathing, coughing, sneezing. Irradiation of pain is not typical for paracostal pleurisy	Sudden acute pain in the chest radiating to the neck, arm, and sometimes to the epigastric region. Increased pain with breathing is less typical than with fibrinous pleurisy
Percussion of the lungs	Usually there are no changes in percussion sound (with the exception of parapneumonic tuberculous, tumor pleurisy)	Tympanitis
Pleural friction rub	Listened to	Absent
Vesicular breathing	Weakened	No sound is heard above the tympanitis zone
Characteristic radiographic signs	High position of the diaphragm dome with The corresponding side, its lag in breathing, limitation of mobility of the lower pulmonary edge	Complete or partial collapse of the lung, displacement of the mediastinum to the opposite side, presence of air in the pleural cavity

Discopathy of the thoracic spine

Discopathy of the thoracic spine (osteochondrosis of the intervertebral discs) also manifests itself with chest pain, often similar to pain in fibrinous pleurisy. Characteristic features of pain in discopathy of the thoracic spine are sudden onset of pain with a sharp change in body position, sharp extension, bending, turning the body; significant reduction in it in the lying position, in a relaxed state, as well as with extension of the spine; often a girdle-like nature of the pain; absence of pleural friction noise. X-ray of the thoracic spine reveals osteochondrosis of the intervertebral discs.

[ 16 ], [ 17 ]