Occupational lung disease differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]


Overview

Occupational lung disease must be differentiated from other diseases that cause shortness of breath, cough, and wheeze, such as allergic asthma, emphysema, sarcoidosis, tuberculosis, and chronic bronchitis.

Differentiating occupational lung disease from other Diseases

Occupational lung disease must be differentiated from other diseases that cause shortness of breath, cough, and wheeze, such as allergic asthma, emphysema, sarcoidosis, tuberculosis, and chronic bronchitis.

Below is a table discussign the differential diagnoses for dyspnea with cough.

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell);

Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Loss of consciousness Agitation Weight loss Fever Chest pain Cough Cyanosis Clubbing JVD Peripheral edema Auscultation CBC ABG Imaging Spirometry Gold standard
Acute Dyspnea Respiratory system Head and Neck,

Upper airway

Angioedema[1] - - - - - +/- - +/- - + Normal Normal ↓O2, ↑CO2 Normal N/A Physical exam Generalized edema
Aspiration[2] - + - - +/- + + - - - Diminished breath sounds Normal Normal Atelectasis ↓Vt, ↑RV Bronchoscopy Choking
Croup[3] - + - +/- - + + - - - Stridor ↑WBC Normal Steeple sign Normal Physical exam Barking cough
Epiglottitis[4] - + - + - + - - - - Stridor ↑WBC Normal Thumb sign Normal Laryngoscopy Drooling
Rhinosinusitis[5] - - - + - +/- - - - - Normal ↑WBC Normal Air fluid level Normal Physical exam Headache
Vocal cord dysfunction[6] - - - - - +/- - - - - Stridor Normal Normal Normal ↓ FVC Laryngoscopy Choking sensation
Chest and Pleura,

Lower airway

Asthma attack[7] - + - - +/- + + - - - Wheeze ↑ Eosinophil Respiratory alkalosis Normal ↓ FEV1, PEF Physical exam and

Spirometry

Chest pain
Bronchitis[8] - - - + + + - - - - Rhonchi  ↑WBC Normal Normal Normal Physical exam Rhonchi relieved by cough
Bronchospasm[9] +/- + - - + +/- + - - - Wheeze Normal ↓O2, ↑CO2 Normal ↓Vt, ↑RV Physical exam Allergic reaction
Bronchiolitis[10] - - - + +/- + - - - - Wheeze and Crackles ↑WBC Normal Bronchovascular markings ↓Vt Clinical assessment Respiratory syncytial virus (RSV)
COPD exacerbation[11] - + - + + + + +/- +/- +/- Wheeze, Rhonchi, and Crackles ↑WBC, ↑RBC Respiratory alkalosis Hyperexpansion ↓ FEV1/FVC Clinical assessment Acute exacerbations of chronic bronchitis (AECB)
Lung carcinoma[12] - - + - - + + + - - Wheeze and Crackles Normal Normal Mass lesion, hilar lymphadenopathy ↓Vt, ↑RV Bronchoscopy  Paraneoplastic syndromes, such as SIADH and lambert-Eaton
Pneumonia[13] - - - + + + - - - - Wheeze, Rhonchi, and Crackles ↑WBC, neutrophilia Normal Lobar consolidation Normal Chest X-ray and CT Scan productive cough
Cardiovascular system Acute heart failure[14] +/- + - - +/- + + - + + S3 Normal Respiratory alkalosis ↑ Cardiothoracic ratio ↓Vt B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) Excessive sweating, high blood pressure
Pulmonary edema[15] +/- + - + + + + + + + Basal crackle Normal Respiratory alkalosis Bat wing pattern, air bronchograms ↓Vt, ↑RV Cardiac Catheterization Tachypnea
Toxic/Metabolic Carbon monoxide poisoning[16] + - - - + + + - - - Wheeze Carboxyhemoglobin ↓O2, ↑CO2 Normal N/A Carboxyhemoglobin (HbCO) level Headache, Dizziness, Weakness, Vomiting, Confusion
Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Loss of consciousness Agitation Weight loss Fever Chest pain Cough Cyanosis Clubbing JVD Peripheral edema Auscultation CBC ABG Imaging Spirometry Gold standard
Chronic Dyspnea Respiratory system Head and Neck,

Upper airway

Laryngeal adenocarcinoma[17] - - + - - +/- - - - - Stridor Normal ↓O2, ↑CO2 Retropharyngeal tissue thickness Normal Laryngoscopy Choking sensation
Vocal cord paralysis[6] - - - - - +/- - - - - Stridor Normal Normal Pharyngeal constrictor muscles thinning, uvular deviation Normal Laryngoscopy Choking sensation
Tracheal stenosis[18] - - - - +/- +/- + + - - Stridor, Stertorous Normal ↓O2, ↑CO2 Soft tissue thickening internal to normal-appearing tracheal cartilage Normal Bronchoscopy Respiratory distress
Chest and Pleura,

Lower airway

Bronchial asthma[7] - + +/- - +/- + + + - - Wheeze ↑ Eosinophil Respiratory alkalosis, Metabolic acidosis Pulmonary hyperinflation,

Bronchial wall thickening

↓ FEV1/FVC Spirometry before and after bronchodilator Paroxysmal respiratory distress
Bronchiectasis[8] - - - + + + + + - - Rhonchi, Wheezing, Crackles ↑WBC, neutrophilia ↓O2, ↑CO2 Tram-track opacities ↑ FEV1/FVC High resolution computed tomography (HRCT) Chronic productive cough
COPD[11] - - +/- - - + + + + +/- Expiratory wheeze ↑ RBC Respiratory alkalosis, Metabolic acidosis ↑ Bronchovascular markings, Cardiomegaly ↓ FEV1/FVC Physical exam and

Spirometry

Heavy smoking history
Emphysema[19] - - - - - +/- + + - - Expiratory wheeze, Hyperinflation Normal Respiratory alkalosis, Metabolic acidosis Flattening of diaphragm, vertical heart ↓ FEV1/FVC Physical exam and

Spirometry

Barrel chest
Pulmonary hypertension[20] - - - - +/- +/- +/- +/- + + Accentuated S2 Normal Hypoxia and acidosis Enlarged pulmonary arteries ↑Physiologic RV Cardiac catheterization Syncope,

Ascites, Pleural effusion

Interstitial lung disease[21] - - - - + + + + - - Rhonchi, Wheezing, Crackles Normal ↓O2, ↑CO2 Peripheral pulmonary infiltrative opacification ↑ FEV1/FVC High resolution computed tomography (HRCT) Pneumoconiosis
Sarcoidosis[22] - - +/- - +/- + + - - - Crackles Normal ↓O2, ↑CO2 Hilar adenopathy ↑ FEV1/FVC High resolution computed tomography (HRCT) Hypercalcemia, high ACE
Alveolitis[23] - - - + + + - - - - Basal crackle ↑WBC, neutrophilia Normal  Basal reticulonodular opacification   ↑ FEV1/FVC High resolution computed tomography (HRCT) Dry cough
Bronchiolitis obliterans[10] - - - + + + + + - - Expiratory wheeze ↑WBC ↓O2, ↑CO2 Hyperinflation, Reticulonodular opacities ↓ FEV1/FVC Lung biopsy Complication of allogeneic hematopoietic stem cell transplantation
Cystic fibrosis[24] - - + + - +/- + + - - Rhonchi, Wheezing, Crackles Normal Metabolic alkalosis Thick-walled bronchiectasis ↓ FEF75%/FVC Sweat test Absent vas deferens
Pulmonary right-to-left shunt[25] - - - - +/- + + + - - Diminished breath sounds Normal ↓O2, ↑CO2, Respiratory acidosis Normal ↓Vt, ↑RV

(physiological)

Pulmonary CT angiography Chronic hypoxemia
Diaphragmatic paralysis[26] - - - +/- +/- +/- - - - - Normal Normal Normal Unilateral or bilateral diaphragmatic flattening ↓Vt, ↑RV

(anatomical)

CXR confirmed by fluoroscopic sniff test Respiratory insufficiency
Tuberculosis[27] - - + + + + +/- - - - Rhonchi, Wheezing, Crackles ↑WBC ↓O2, ↑CO2 Patchy consolidation or poorly defined linear and nodular opacities Restrictive, obstructive, or mixed IFN-γ release assay (IGRA)

Acid-fast staining

Night sweat
Cardiovascular system Pericardial effusion[28] - - - +/- + + - - + - Muffled heart sounds Normal Normal Fluid density around the heart Normal M-mode and 2-dimensional Doppler echocardiography Hoarseness, Palpitation
Systemic Anxiety[29] + + + - +/- +/- - - - - Normal Normal Normal Normal Normal Psychological interview Sweating, Palpitation
Autoimmune Churg-Strauss syndrome[30] - - - - - + - - - - Scattered wheezing Normal Normal Areas of parenchymal opacification ↓Vt, ↑RV Biopsy  Fatigue,Numbness
Wegener's granulomatosis[31] - - +/- - - + - - - - Wheezing, Crackles ↓ RBC ↓O2, ↑CO2 Cavitate nodules, ground-glass opacity ↓ FEV1/FVC Biopsy demonstrating a granulomatous vasculitis Chronic rhinosinusitis
Goodpasture's disease[32] - - - - - + - - - -  Bilateral coarse crepitations ↓ RBC, HGB, HCT Normal  Like pulmonary edema Normal Kidney biopsy Hematuria,

Hemoptysis


References

  1. ↑ Bernstein JA, Cremonesi P, Hoffmann TK, Hollingsworth J (2017). "Angioedema in the emergency department: a practical guide to differential diagnosis and management". Int J Emerg Med. 10 (1): 15. doi:10.1186/s12245-017-0141-z. PMC 5389952. PMID 28405953.
  2. ↑ O'Horo JC, Rogus-Pulia N, Garcia-Arguello L, Robbins J, Safdar N (2015). "Bedside diagnosis of dysphagia: a systematic review". J Hosp Med. 10 (4): 256–65. doi:10.1002/jhm.2313. PMC 4607509. PMID 25581840.
  3. ↑ Bjornson CL, Johnson DW (2013). "Croup in children". CMAJ. 185 (15): 1317–23. doi:10.1503/cmaj.121645. PMC 3796596. PMID 23939212.
  4. ↑ Negus VE (1927). "The Function of the Epiglottis". J Anat. 62 (Pt 1): 1–8. PMC 1250045. PMID 17104162.
  5. ↑ Meltzer EO, Hamilos DL (2011). "Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines". Mayo Clin Proc. 86 (5): 427–43. doi:10.4065/mcp.2010.0392. PMC 3084646. PMID 21490181.
  6. ↑ 6.0 6.1 Wood RP, Milgrom H (September 1996). "Vocal cord dysfunction". J. Allergy Clin. Immunol. 98 (3): 481–5. PMID 8828523.
  7. ↑ 7.0 7.1 Hodder R, Lougheed MD, Rowe BH, FitzGerald JM, Kaplan AG, McIvor RA (2010). "Management of acute asthma in adults in the emergency department: nonventilatory management". CMAJ. 182 (2): E55–67. doi:10.1503/cmaj.080072. PMC 2817338. PMID 19858243.
  8. ↑ 8.0 8.1 Cantin, Luce; Bankier, Alexander A.; Eisenberg, Ronald L. (2009). "Bronchiectasis". American Journal of Roentgenology. 193 (3): W158–W171. doi:10.2214/AJR.09.3053. ISSN 0361-803X.
  9. ↑ Molis MA, Molis WE (2010). "Exercise-induced bronchospasm". Sports Health. 2 (4): 311–7. doi:10.1177/1941738110373735. PMC 3445098. PMID 23015953.
  10. ↑ 10.0 10.1 Holbro A, Lehmann T, Girsberger S, Stern M, Gambazzi F, Lardinois D, Heim D, Passweg JR, Tichelli A, Bubendorf L, Savic S, Hostettler K, Grendelmeier P, Halter JP, Tamm M (2013). "Lung histology predicts outcome of bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation". Biol. Blood Marrow Transplant. 19 (6): 973–80. doi:10.1016/j.bbmt.2013.03.017. PMID 23562737.
  11. ↑ 11.0 11.1 Qureshi H, Sharafkhaneh A, Hanania NA (2014). "Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications". Ther Adv Chronic Dis. 5 (5): 212–27. doi:10.1177/2040622314532862. PMC 4131503. PMID 25177479.
  12. ↑ Dela Cruz CS, Tanoue LT, Matthay RA (2011). "Lung cancer: epidemiology, etiology, and prevention". Clin Chest Med. 32 (4): 605–44. doi:10.1016/j.ccm.2011.09.001. PMC 3864624. PMID 22054876.
  13. ↑ Simonetti AF, Viasus D, Garcia-Vidal C, Carratalà J (2014). "Management of community-acquired pneumonia in older adults". Ther Adv Infect Dis. 2 (1): 3–16. doi:10.1177/2049936113518041. PMC 4072047. PMID 25165554.
  14. ↑ Gaggin, Hanna K.; Januzzi, James L. (2013). "Biomarkers and diagnostics in heart failure". Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease. 1832 (12): 2442–2450. doi:10.1016/j.bbadis.2012.12.014. ISSN 0925-4439.
  15. ↑ Martindale, Jennifer L.; Noble, Vicki E.; Liteplo, Andrew (2013). "Diagnosing pulmonary edema". European Journal of Emergency Medicine. 20 (5): 356–360. doi:10.1097/MEJ.0b013e32835c2b88. ISSN 0969-9546.
  16. ↑ Lane TR, Williamson WJ, Brostoff JM (2008). "Carbon monoxide poisoning in a patient with carbon dioxide retention: a therapeutic challenge". Cases J. 1 (1): 102. doi:10.1186/1757-1626-1-102. PMC 2533003. PMID 18710551.
  17. ↑ Schwenk NR, Schapira RM, Byrd JC (November 1994). "Laryngeal carcinoma presenting as platypnea". Chest. 106 (5): 1609–11. PMID 7956433.
  18. ↑ Conti V, Calia N, Pasquini C, Zardi S, Finetti C, Stomeo F, Ravenna F (April 2013). "[Chronic cough and worsening dyspnea: a case of idiopathic tracheal stenosis]". Recenti Prog Med (in Italian). 104 (4): 156–8. doi:10.1701/1271.14026. PMID 23748638.
  19. ↑ Sharafkhaneh A, Hanania NA, Kim V (2008). "Pathogenesis of emphysema: from the bench to the bedside". Proc Am Thorac Soc. 5 (4): 475–7. doi:10.1513/pats.200708-126ET. PMC 2645322. PMID 18453358.
  20. ↑ Sajkov D, Petrovsky N, Palange P (June 2010). "Management of dyspnea in advanced pulmonary arterial hypertension". Curr Opin Support Palliat Care. 4 (2): 76–84. doi:10.1097/SPC.0b013e328338c1e0. PMID 20407377.
  21. ↑ Baughman RP, Shipley RT, Loudon RG, Lower EE (1991). "Crackles in interstitial lung disease. Comparison of sarcoidosis and fibrosing alveolitis". Chest. 100 (1): 96–101. PMID 2060395.
  22. ↑ Moher D, Cole CW, Hill GB (November 1992). "Epidemiology of abdominal aortic aneurysm: the effect of differing definitions". Eur J Vasc Surg. 6 (6): 647–50. PMID 1451823.
  23. ↑ Khanna D, Clements PJ, Furst DE, Chon Y, Elashoff R, Roth MD, Sterz MG, Chung J, FitzGerald JD, Seibold JR, Varga J, Theodore A, Wigley FM, Silver RM, Steen VD, Mayes MD, Connolly MK, Fessler BJ, Rothfield NF, Mubarak K, Molitor J, Tashkin DP (February 2005). "Correlation of the degree of dyspnea with health-related quality of life, functional abilities, and diffusing capacity for carbon monoxide in patients with systemic sclerosis and active alveolitis: results from the Scleroderma Lung Study". Arthritis Rheum. 52 (2): 592–600. doi:10.1002/art.20787. PMID 15692967.
  24. ↑ Ziegler, Bruna; Rovedder, Paula Maria Eidt; Dalcin, Paulo de Tarso Roth; Menna-Barreto, Sérgio Saldanha (2009). "Padrões ventilatórios na espirometria em pacientes adolescentes e adultos com fibrose cística". Jornal Brasileiro de Pneumologia. 35 (9): 854–859. doi:10.1590/S1806-37132009000900006. ISSN 1806-3713.
  25. ↑ Vodoz JF, Cottin V, Glérant JC, Derumeaux G, Khouatra C, Blanchet AS; et al. (2009). "Right-to-left shunt with hypoxemia in pulmonary hypertension". BMC Cardiovasc Disord. 9: 15. doi:10.1186/1471-2261-9-15. PMC 2671488. PMID 19335916.
  26. ↑ Dubé BP, Dres M (2016). "Diaphragm Dysfunction: Diagnostic Approaches and Management Strategies". J Clin Med. 5 (12). doi:10.3390/jcm5120113. PMC 5184786. PMID 27929389.
  27. ↑ Campbell IA, Bah-Sow O (2006). "Pulmonary tuberculosis: diagnosis and treatment". BMJ. 332 (7551): 1194–7. doi:10.1136/bmj.332.7551.1194. PMC 1463969. PMID 16709993.
  28. ↑ Jung HO (2012). "Pericardial effusion and pericardiocentesis: role of echocardiography". Korean Circ J. 42 (11): 725–34. doi:10.4070/kcj.2012.42.11.725. PMC 3518705. PMID 23236323.
  29. ↑ Bailey PH (July 2004). "The dyspnea-anxiety-dyspnea cycle--COPD patients' stories of breathlessness: "It's scary /when you can't breathe"". Qual Health Res. 14 (6): 760–78. doi:10.1177/1049732304265973. PMID 15200799.
  30. ↑ Uyar M, Elbek O, Bakır K, Kibar Y, Bayram N, Dikensoy Ö (2012). "Churg-Strauss syndrome related to montelukast". Tuberk Toraks. 60 (1): 56–8. PMID 22554368.
  31. ↑ Cardenas-Garcia J, Farmakiotis D, Baldovino BP, Kim P (2012). "Wegener's granulomatosis in a middle-aged woman presenting with dyspnea, rash, hemoptysis and recurrent eye complaints: a case report". J Med Case Rep. 6: 335. doi:10.1186/1752-1947-6-335. PMC 3492078. PMID 23034218.
  32. ↑ Bal, Amanjit; Das, Ashim; Gupta, Dheeraj; Garg, Mandeep (2014). "Goodpasture's Syndrome and p-ANCA Associated Vasculitis in a Patient of Silicosiderosis: An Unusual Association". Case Reports in Pulmonology. 2014: 1–7. doi:10.1155/2014/398238. ISSN 2090-6846.
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