Non-pleuritic chest pain and recurrent lobar collapse
Article Outline
Summary
Respiratory chest pain is usually pleuritic in origin although the bronchi have been described as having pain sensation. A subject with chronic bronchitis presented with 4 episodes of collapse of her left lower lobe documented on X-ray. Each of these episodes was associated with non-pleuritic chest pain over the left lower lobe of moderate severity that resolved with antibiotic treatment. Follow-up X-rays demonstrated lung re-inflation. The suggestion from this case is that lobar collapse which probably occurred from atelectasis; is associated with a distinctive type of chest pain. Awareness of this symptom may facilitate an earlier diagnosis of pulmonary collapse.
Keywords: Chest pain, Lobar collapse, Atelectasis
Introduction
Chest pain is an important symptom in respiratory disease and most commonly occurs from involvement of the pleural surface1. The bronchi are also known to have pain sensation but pain involving bronchial structures has not been well characterised. A patient presented with 4 distinct episodes of non-pleuritic chest pain with left lower lobe collapse on X-ray Fig. 1. The chest pain resolved with re-inflation of the lung. This case suggests that non-pleuritic chest pain is an early symptom of pulmonary collapse and the possible mechanism may involve pulmonary stretch receptors.
Figure 1
A) left lower lobe collapse in association with chest pain B) resolution of left lower lobe collapse with resolution of chest pain.
Case report
A sixty-three year old woman presented for assessment of recurrent chest pain. She was a current smoker with a forty-year pack-history who had developed symptoms of chronic bronchitis over the past 5 years, with a cough productive of 5–15
mls of mucoid sputum on most days. She was otherwise well with no other major medical problems and was very active with a good exercise tolerance.
Over the past 8 months she described 3 episodes of chest pain all of which had the same characteristics. Each of these episodes had no clear precipitating factor and the pain came on acutely over approximately a 1h period. The pain was described as being moderately severe, rated as 7 on numerical pain rating score (with 0 being no pain and 10 being the worst possible pain)1 and of a continuous squeezing character. The pain was not pleuritic; there was no association with movement or respiration. On two occasions this pain was described as being located over the lower left lung and on one occasion being located over both lower lungs. Several days after the onset of the pain the patient was aware of increased frequency and volume of a productive cough with a change in sputum consistency to being more purulent and yellow. There was also moderate associated breathlessness. The first episode of chest pain lasted a week before a chest X-ray (CXR) was performed which demonstrated collapse of the left lower lobe. As the patient has discoloured sputum it was assumed that a bacterial lower respiratory tract infection was likely. Therefore she was then treated with a 2 week course of antibiotics and her chest pain gradually subsided over the next week. A repeat CXR demonstrated re-inflation of the left lower lobe. She had 2 more similar episodes (each of them with purulent sputum production) left lower collapse demonstrated on CXR and each episode improved over the space of a week with antibiotics. For the third episode the patient had a CT scan of her lungs which demonstrated atelectasis and complete collapse of the left lower lobe.
She was referred for review and seen by the author 2 days after the CT. She still had some mild chest pain and increased productive cough with purulent sputum at the time. Clinical assessment revealed no evidence of extra-pulmonary disease. Cardiovascular, respiratory, musculoskeletal, and gastrointestinal examinations were unremarkable. A bronchoscopy was performed (after resolution of chest pain) which demonstrated thick mucus in her right bronchial tree but no abnormality on the left side or evidence of an endobronchial lesion. Spirometry demonstrated normal lung function. A high resolution CT scan was done 2 months later which showed some minimal bronchiectasis in the right lower lobe and minimal atelectasis in the lingula.
She was subsequently followed up by the author over the next 2 years. She had another similar episode of non-pleuritic chest pain and CXR demonstrated left lower lobe collapse and atelectasis. Her symptoms improved in a few days with antibiotics and follow-up X-ray demonstrated lung re-inflation.
Discussion
Respiratory chest pain is most commonly pleuritic arising from involvement of nerve fibers in the parietal pleura occurring in the context of respiratory infection, malignancy, pulmonary embolism and pneumothorax. The alveoli have been described as lacking pain sensation, although pain may arise from the bronchi.2, 3
This patient had 4 episodes of distinctive chest pain associated with lobar collapse. This lobar collapse appeared to be secondary to atelectasis and resolution of pain and lobar collapse coincided with antibiotic treatment. The purulent sputum production and sputum retention is presumably the cause of the atelectasis. This is suggested by the improvement that occurred with antibiotic treatment. Interestingly in 3 of the 4 episodes the chest pain was the first symptom of clinical deterioration which was followed by increased productive cough. The right middle lobe syndrome is characterised by bronchial obstruction and has been associated with chest pain4; this pain has not been well defined.
The mechanism of the chest pain in this patient was not clear. Pain may arise from surface structures (e.g. pleura/skin) or viscera. Visceral pain is usually poorly localized and may arise from several mechanisms including ischemia, chemical stimuli and overdistention.3 Stretch receptors are present in the bronchi with slowly adapting receptors in the tracheobronchial smooth muscle and rapidly adapting receptors in the superficial mucosal layer.5, 6 It is possible that the pain in this subject may have arisen from stimulation of the stretch receptors in the bronchi and this subsided with re-inflation of the lung.
The suggestion from this case is that collapse of the lung/atelectasis is associated with distinctive chest pain and awareness of this symptom may facilitate early diagnosis.
Conflict of interest statement
The author has no conflict of interest in this work.
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PII: S1755-0017(08)00108-5
doi:10.1016/j.rmedc.2008.12.007
© 2009 Elsevier Ltd. All rights reserved.
