Non-bacterial thrombotic endocarditis differential diagnosis: Difference between revisions

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{{non-bacterial thrombotic endocarditis}}
{{non-bacterial thrombotic endocarditis}}


{{CMG}}; {{AE}}{{Homa}}
{{CMG}}; {{AE}}{{Aisha}}
==Overview==
==Overview==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
[[Non-bacterial thrombotic endocarditis]] must be differentiated from other [[diseases]] that cause a new or changed [[heart murmur]], multiple [[Systemic embolization|systemic emboli]], +/-[[fever]], such as [[infective endocarditis]], [[Valvular Diseases|degenerative valvular disease]], and [[Pulmonary embolism|pulmonary infarction]].
 
OR
 
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
 
==Differentiating [Disease name] from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
 
OR
 
[Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].
 
OR
 
As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].


===Differentiating [disease name] from other diseases on the basis of [symptom 1], [symptom 2], and [symptom 3]===
==Differential Diagnosis==
[[Non-bacterial thrombotic endocarditis]] must be differentiated from other [[diseases]] that cause a new or changed [[heart murmur]], multiple [[Systemic embolization|systemic emboli]], +/-[[fever]], such as;<ref name="urlLibman-Sacks Endocarditis Differential Diagnoses">{{cite web |url=https://emedicine.medscape.com/article/155230-differential |title=Libman-Sacks Endocarditis Differential Diagnoses |format= |work= |accessdate=}}</ref><ref name="urlNonbacterial Thrombotic Endocarditis: Clinicopathologic Study of a Necropsy Series | Revista Española de Cardiología (English Edition)">{{cite web |url=https://www.revespcardiol.org/en-nonbacterial-thrombotic-endocarditis-clinicopathologic-study-articulo-13106392 |title=Nonbacterial Thrombotic Endocarditis: Clinicopathologic Study of a Necropsy Series &#124; Revista Española de Cardiología (English Edition) |format= |work= |accessdate=}}</ref><ref name="pmid3548296">{{cite journal |vauthors=Lopez JA, Ross RS, Fishbein MC, Siegel RJ |title=Nonbacterial thrombotic endocarditis: a review |journal=Am. Heart J. |volume=113 |issue=3 |pages=773–84 |date=March 1987 |pmid=3548296 |doi=10.1016/0002-8703(87)90719-8 |url=}}</ref><ref name="pmid15919332">{{cite journal |vauthors=Borowski A, Ghodsizad A, Cohnen M, Gams E |title=Recurrent embolism in the course of marantic endocarditis |journal=Ann. Thorac. Surg. |volume=79 |issue=6 |pages=2145–7 |date=June 2005 |pmid=15919332 |doi=10.1016/j.athoracsur.2003.12.024 |url=}}</ref><ref name="pmid16965557">{{cite journal |vauthors=Aryana A, Esterbrooks DJ, Morris PC |title=Nonbacterial thrombotic endocarditis with recurrent embolic events as manifestation of ovarian neoplasm |journal=J Gen Intern Med |volume=21 |issue=12 |pages=C12–5 |date=December 2006 |pmid=16965557 |pmc=1924740 |doi=10.1111/j.1525-1497.2006.00614.x |url=}}</ref><ref name="pmid11988602">{{cite journal |vauthors=Singhal AB, Topcuoglu MA, Buonanno FS |title=Acute ischemic stroke patterns in infective and nonbacterial thrombotic endocarditis: a diffusion-weighted magnetic resonance imaging study |journal=Stroke |volume=33 |issue=5 |pages=1267–73 |date=May 2002 |pmid=11988602 |doi=10.1161/01.str.0000015029.91577.36 |url=}}</ref>.
*[[Infective endocarditis]],  
*[[Valvular Diseases|Degenerative valvular disease]], and
*[[Pulmonary embolism|Pulmonary infarction]].


On the basis [symptom 1], [symptom 2], and [symptom 3], [disease name] must be differentiated from [disease 1], [disease 2], [disease 3], [disease 4], [disease 5], and [disease 6].
<small>
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|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;|Diseases
! rowspan="2" |<small>Diseases</small>
| colspan="6" rowspan="1"  style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Clinical manifestations'''
! colspan="3" |<small>Diagnostic tests</small>
! colspan="7" rowspan="2"  style="background: #4479BA; color: #FFFFFF; text-align: center;|Para-clinical findings
! colspan="3" |<small>Physical Examination</small>
| colspan="1" rowspan="4"  style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Gold standard'''
| colspan="7" |<small>Symptoms
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;|Additional findings
! colspan="1" rowspan="2" |<small>Past medical history</small>
|-
! rowspan="2" |<small>Other Findings</small>
| colspan="3" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Symptoms'''
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! colspan="3" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical examination
!<small>CT scan and MRI</small>
|-
!<small>EKG</small>
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab Findings
!<small>Chest X-ray</small> 
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging
!<small>Tachypnea</small>
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|Histopathology
!<small>Tachycardia</small>
|-
!<small>Fever</small>
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 1
!<small>Chest Pain</small>
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 2
!<small>Hemoptysis</small>
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 3
!<small>Dyspnea on Exertion</small>
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 1
!<small>Wheezing</small>
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 2
!<small>Chest Tenderness</small>
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 3
!<small>Nasalopharyngeal Ulceration</small>
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 1
!<small>Carotid Bruit</small>
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 3
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 1
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 3
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 1
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pulmonary embolism]]
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* On [[CT angiography]]:
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** Intra-luminal filling defect
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*On [[MRI]]:
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** Narrowing of involved [[Blood vessel|vessel]]
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** No contrast seen distal to [[obstruction]]
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** Polo-mint sign (partial filling defect surrounded by contrast)
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* [[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain
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* [[Fleischner sign]] (enlarged pulmonary artery), [[Hampton's hump|Hampton hump]], [[Westermark's sign]]
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔ (Low grade)
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔ (In case of massive PE)
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| style="background: #F5F5F5; padding: 5px;" | -
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*Hypercoagulating conditions ([[Factor V Leiden]], [[thrombophilia]], [[deep vein thrombosis]], immobilization, [[malignancy]], [[pregnancy]])
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* May be associated with [[metabolic alkalosis]] and [[syncope]]
|-
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 2
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Infective Endocarditis]]
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*Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
**[[S wave|S]]V1 or [[S wave|S]]V2 + [[R wave|R]]V5 or [[R wave|R]]V6 ≥3.5 mV
**Total [[QRS complex|QRS]] amplitude in each of the limb leads ≤0.8 mV
** [[R wave|R]]/[[S wave|S]] ratio <1 in lead V4
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| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
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*Previous [[myocardial infarction]]
*[[Hypertension]] ([[Systemic hypertension|systemic]] and [[Pulmonary hypertension|pulmonary]])
*[[Cardiac arrhythmia|Cardiac arrythmias]]
*[[Viral]] infections ([[myocarditis]])
*[[Congenital heart disease|Congenital heart defects]]
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*[[Right heart failure]] associated with:
**[[Hepatomegaly]]
**Positive hepato-jugular reflex
**Increased [[jugular venous pressure]]
**[[Peripheral edema]]
*[[Left heart failure]] associated with:
**[[Pulmonary edema]]
**Eventual [[right heart failure]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 3
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Non-bacterial thrombotic endocarditis|Non-bacterial thrombotic endocarditis]]
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*ST elevation
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*PR depression
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| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔ (Low grade)
| style="background: #F5F5F5; padding: 5px;" |✔ (Relieved by sitting up and leaning forward)
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
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*Infections:
**[[Viral]] (Coxsackie virus, [[Herpes simplex virus|Herpes virus]], [[Mumps virus]], [[Human Immunodeficiency Virus (HIV)|HIV]])
**[[Bacteria]] ([[Mycobacterium tuberculosis]]-common in developing countries)
**[[Fungal]] ([[Histoplasmosis]])
*Idiopathic in a large number of cases
*[[Autoimmune]]
*[[Uremia]]
*[[Malignancy]]
*Previous [[myocardial infarction]]
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*May be clinically classified into:
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**Acute (< 6 weeks)
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**Sub-acute (6 weeks - 6 months)
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**Chronic (> 6 months)
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|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Diseases
!Symptom 1
! colspan="1" rowspan="1" |Symptom 2
!Symptom 3
!Physical exam 1
! colspan="1" rowspan="1" |Physical exam 2
!Physical exam 3
!Lab 1
!Lab 2
!Lab 3
!Imaging 1
!Imaging 2
!Imaging 3
!Histopathology
|'''Gold standard'''
!Additional findings
|-
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 4
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Libman Sack Endocarditis]]
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*Prolonged [[PR interval]]
*Transient [[T wave]] inversions
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
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*Ill-contact
*Travelling
*[[Smoking]]
*[[Diabetes mellitus|Diabetic]]
*Recent hospitalization
*[[Chronic obstructive pulmonary disease]]
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*Requires [[Sputum|sputum stain]] and culture for diagnosis
*[[Empiric therapy|Empiric management]] usually started before [[Culture collection|culture]] results
|-
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 5
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Vasculitis]]
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*On [[Computed tomography|CT scan]]: ([[Takayasu's arteritis|Takayasu arteritis]])
**[[Blood vessel|Vessel]] wall thickening
**Luminal narrowing of [[pulmonary artery]]
**Masses or nodules ([[Anti-neutrophil cytoplasmic antibody|ANCA]]-associated granulomatous vasculitis)
*On [[Magnetic resonance imaging|MRI]]:
Homogeneous, circumferential [[Blood vessel|vessel]] wall [[swelling]]
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*[[Bundle branch block|Right or left bundle-branch block]] ([[Churg-Strauss syndrome]])
*[[Atrial fibrillation]] ([[Churg-Strauss syndrome]])
*Non-specific [[ST interval|ST segment]] and [[T wave]] changes
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*[[Nodule (medicine)|Nodules]]
*[[Cavitation]]
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
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*[[Takayasu's arteritis|Takayasu arteritis]] usually found in persons aged 4-60 years with a mean of 30
*[[Giant-cell arteritis]] usually occurrs in persons aged > 60 years
*[[Churg-Strauss syndrome]] may present with [[asthma]], [[sinusitis]], transient [[pulmonary]] infiltrates and neuropathy alongwith [[cardiac]] involvement
*Granulomatous vasculitides may present with [[nephritis]] and [[upper airway]] ([[nasopharyngeal]]) destruction
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|-
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 6
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Fever of unknown origin]] (FUO)
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*[[Multifocal atrial tachycardia]] (atleast 3 distinct [[P waves|P wave]] morphologies)
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| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
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*[[Smoking]]
*[[Alpha 1-antitrypsin deficiency|Alpha-1 antitrypsin deficiency]]
*Increased [[sputum]] production ([[chronic bronchitis]])
*[[Cough]]
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*[[Alpha 1-antitrypsin deficiency|Alpha 1 antitrypsin deficiency]] may be associated with [[hepatomegaly]]
|}
|}
==Differentiating [Disease name] from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
OR
[Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].
OR
As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].


==References==
==References==

Latest revision as of 19:11, 6 August 2020

non-bacterial thrombotic endocarditis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2]

Overview

Non-bacterial thrombotic endocarditis must be differentiated from other diseases that cause a new or changed heart murmur, multiple systemic emboli, +/-fever, such as infective endocarditis, degenerative valvular disease, and pulmonary infarction.

Differential Diagnosis

Non-bacterial thrombotic endocarditis must be differentiated from other diseases that cause a new or changed heart murmur, multiple systemic emboli, +/-fever, such as;[1][2][3][4][5][6].

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
CT scan and MRI EKG Chest X-ray Tachypnea Tachycardia Fever Chest Pain Hemoptysis Dyspnea on Exertion Wheezing Chest Tenderness Nasalopharyngeal Ulceration Carotid Bruit
Pulmonary embolism
  • On CT angiography:
    • Intra-luminal filling defect
  • On MRI:
    • Narrowing of involved vessel
    • No contrast seen distal to obstruction
    • Polo-mint sign (partial filling defect surrounded by contrast)
 ✔ ✔ ✔ (Low grade) ✔ ✔ (In case of massive PE) ✔ - - - -
Infective Endocarditis
  • Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
    • SV1 or SV2 + RV5 or RV6 ≥3.5 mV
    • Total QRS amplitude in each of the limb leads ≤0.8 mV
    • R/S ratio <1 in lead V4
 ✔ ✔ ✔ - - ✔ - - - -
Non-bacterial thrombotic endocarditis
  • ST elevation
  • PR depression
 ✔ ✔ ✔ (Low grade) ✔ (Relieved by sitting up and leaning forward) - ✔ - - - -
  • May be clinically classified into:
    • Acute (< 6 weeks)
    • Sub-acute (6 weeks - 6 months)
    • Chronic (> 6 months)
Libman Sack Endocarditis ✔ ✔ ✔ ✔ - ✔ ✔ - - -
Vasculitis

Homogeneous, circumferential vessel wall swelling

✔ ✔ ✔ ✔ ✔ ✔ - ✔ ✔ ✔
Fever of unknown origin (FUO) ✔ ✔ - - - ✔ ✔ - - -

Differentiating [Disease name] from other Diseases

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].

OR

As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].


References

  1. ↑ "Libman-Sacks Endocarditis Differential Diagnoses".
  2. ↑ "Nonbacterial Thrombotic Endocarditis: Clinicopathologic Study of a Necropsy Series | Revista Española de Cardiología (English Edition)".
  3. ↑ Lopez JA, Ross RS, Fishbein MC, Siegel RJ (March 1987). "Nonbacterial thrombotic endocarditis: a review". Am. Heart J. 113 (3): 773–84. doi:10.1016/0002-8703(87)90719-8. PMID 3548296.
  4. ↑ Borowski A, Ghodsizad A, Cohnen M, Gams E (June 2005). "Recurrent embolism in the course of marantic endocarditis". Ann. Thorac. Surg. 79 (6): 2145–7. doi:10.1016/j.athoracsur.2003.12.024. PMID 15919332.
  5. ↑ Aryana A, Esterbrooks DJ, Morris PC (December 2006). "Nonbacterial thrombotic endocarditis with recurrent embolic events as manifestation of ovarian neoplasm". J Gen Intern Med. 21 (12): C12–5. doi:10.1111/j.1525-1497.2006.00614.x. PMC 1924740. PMID 16965557.
  6. ↑ Singhal AB, Topcuoglu MA, Buonanno FS (May 2002). "Acute ischemic stroke patterns in infective and nonbacterial thrombotic endocarditis: a diffusion-weighted magnetic resonance imaging study". Stroke. 33 (5): 1267–73. doi:10.1161/01.str.0000015029.91577.36. PMID 11988602.

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