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Stab-like localized chest pain, aggravated by breathing, is compatible with pleuritic pain or with aching related to chest wall abnormalities. Local tenderness inflicted by palpation helps to differentiate pleuritic from musculoskeletal chest pain and serves as a principal accessory manoeuvre in the algorithm of chest pain evaluation. Herein, we report the case of a 27-year-old patient with pulmonary thromboembolism and right lower lobe consolidation/atelectasis. The patient presented with right-sided chest pain, radiating to the shoulder, related to pleural irritation, yet associated with confounding intense chest wall tenderness and guarding, also involving the costovertebral angle. We propose that spinal reflex-related chest wall tenderness was involved, similar to peritoneal signs evoked by irritation of the parietal peritoneum. This case report illustrates that localized chest wall tenderness and guarding, triggered by palpation, may not serve as unequivocal indicators of musculoskeletal pain, and could be unrecognized features of pleuritic chest pain also., Learning Points: Pleuritic chest pain may be associated with local tenderness and guarding.These unrecognized features of pleurisy supposedly reflect a spinal reflex, initiated by nociceptors in the parietal pleura.Local pain inflicted upon palpation and guarding may not serve as unequivocal indicators of musculoskeletal chest pain., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2020.)