Deep vein thrombosis differential diagnosis: Difference between revisions

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'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org]; '''Associate Editor(s)-In-Chief:''' {{CZ}} [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]; [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]
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| <figure-inline><figure-inline>[[File:Siren.gif|link=Deep vein thrombosis resident survival guide|41x41px]]</figure-inline></figure-inline>|| <br> || <br>
| [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}} [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]


{{Deep vein thrombosis}}
{{Deep vein thrombosis}}
    
    
==Overview==
==Overview==
Only 25% of the patient evaluated for [[deep vein thrombosis]] (DVT) have the disease.<ref name="pmid3951515">{{cite journal| author=Huisman MV, Büller HR, ten Cate JW, Vreeken J| title=Serial impedance plethysmography for suspected deep venous thrombosis in outpatients. The Amsterdam General Practitioner Study. | journal=N Engl J Med | year= 1986 | volume= 314 | issue= 13 | pages= 823-8 | pmid=3951515 | doi=10.1056/NEJM198603273141305 | pmc= | url= }} </ref> DVT is characterized by pain and swelling of the limb, which is not specific. Numerous patients with DVT are asymptomatic.
Deep vein thrombosis [[DVT]] is characterized by pain and swelling of the limb, which are not specific symptoms. There are other conditions that can mimic DVT such as  [[muscle strain]] or muscle tear, immobilization that led to leg swelling, [[lymphedema]], [[lymphangitis]], [[chronic venous insufficiency]], or [[cellulitis]].


==Differential Diagnosis==
==Differential Diagnosis==
Following conditions should be kept in mind while diagnosing [[DVT]]:
Deep vein thrombosis must be differentiated from other causes of [[lower limb]] [[edema]] like [[chronic venous insufficiency]], [[lymphatic filariasis]], [[lipedema]], [[myxedema]], [[cellulitis]] and causes of [[generalized edema]].
* Muscle tear, strain of leg
* Leg swelling in a paralyzed limb
* [[Lymphangitis]] or lymph obstruction
* Venous insufficiency
* Popliteal/[[Baker's cyst]]
* [[Cellulitis]]
* Knee abnormality


[[Category:Hematology]]
{| class="wikitable"
[[Category:Pulmonology]]
 
[[Category:Cardiology]]
|-
[[Category:Emergency medicine]]
 
! rowspan="2" | Diseases
 
! colspan="7" |Symptoms
 
! rowspan="2" | Signs
 
! rowspan="2" | Gold standard Investigation to diagnose
|-
!History
!Onset
!Pain
!Fever
!Laterality
!Scrotal swelling
!Symptoms of primary disease
|-
!Acute deep venous thrombosis
|
* History of prolonged recumbency
* Classic symptoms of [[DVT]] include acute unilateral [[swelling]], [[pain]], and [[erythema]] 
|Acute
| +
| -
|Unilateral
| -
|May be associated with primary disease mandates recumbency for long duration
|
* Dilated [[superficial veins]]
* Difference in [[Calf muscle|calf]] diameter is twice as likely to have [[DVT]](most impotant sign )<ref name="pmid16027455">{{cite journal| author=Goodacre S, Sutton AJ, Sampson FC| title=Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis. | journal=Ann Intern Med | year= 2005 | volume= 143 | issue= 2 | pages= 129-39 | pmid=16027455 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16027455  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16539361 Review in: ACP J Club. 2006 Mar-Apr;144(2):46-7]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17213086 Review in: Evid Based Med. 2006 Apr;11(2):56]</ref>
* Calf pain on passive [[dorsiflexion]] of the [[foot]] ([[Homan's sign]]) isn't realiable sign.
 
|
* [[Compression ultrasonography]] (CUS) with [[Doppler ultrasound|doppler]] is the diagnostic test of choice
* [[D-dimer]] level is used for unprobable cases
|-
 
! [[Lymphatic filariasis]]
 
|
* History of living in endemic area or travelling to it
|Chronic
|<nowiki>+</nowiki>
| +
|Bilateral
| +
|<nowiki>-</nowiki>
|
* [[Hepatomegaly]]
* [[Lymphedema]]
* [[Elephantiasis]]
* [[Lymphangitis]]
* [[Hydrocele]]
* Scrotal [[elephantiasis]]
* [[Lymphadenopathy|Lymphadenopathies]]
* [[Rhonchi]] may be present in patients with Pulmonary tropical eosinophilia syndrome.
|
'''Preparing blood smears'''
* Thick smears
# Thick smears consist of a thick layer of dehemoglobinized (lysed) [[Red blood cell|red blood cells]] (RBCs). 
# Thick smears allow a more efficient detection of parasites (increased sensitivity).
* Thin smears consist of [[blood]] spread in a layer such that the thickness decrease.
'''By the ultrasound''', the following findings can be observed:
* Dilated lymphatic channels
* Living worms tend to be in motion which called "filarial dance" sign.
 
|-
 
! [[Chronic venous insufficiency]]
 
|
* History of untreated [[varicose veins]]
* Painful bilateral [[lower limb]] [[swelling]] that increases with standing and decreases by rest and [[leg]] elevation.
|Chronic
|<nowiki>+</nowiki>
| -
|Bilateral
| +
 
(If congenial)
| -
|
* Typical varicose veins
* [[Skin]] change distribution correlate with varicose veins sites in the medial side of [[ankle]] and [[leg]]
* Reduction of [[swelling]] with limb elevation.
|
* [[Duplex ultrasound]] will demonstrate typical findings of [[Venous insufficiency|venous valvular insufficiency]]
|-
![[Lipedema]]
|
* Family history especially in women; [[X-linked dominant]] or [[autosomal dominant]] condition.<ref name="pmid20358611">{{cite journal| author=Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S et al.| title=Lipedema: an inherited condition. | journal=Am J Med Genet A | year= 2010 | volume= 152A | issue= 4 | pages= 970-6 | pmid=20358611 | doi=10.1002/ajmg.a.33313 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20358611  }}</ref>
* Abnormal deposition of fat and [[edema]] and [[easy bruising]].
|Chronic
| +
| -
|Bilateral
| -
|<nowiki>-</nowiki>
|
* Tender with palpation
 
* Negative '''Semmer sign''' to differentiate from lymphedema.<ref name="pmid23939641">{{cite journal| author=Trayes KP, Studdiford JS, Pickle S, Tully AS| title=Edema: diagnosis and management. | journal=Am Fam Physician | year= 2013 | volume= 88 | issue= 2 | pages= 102-10 | pmid=23939641 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23939641  }}</ref>
* Pinching the [[skin]] on the upper surface of the [[toes]]. If it is possible to grasp a thin fold of [[tissue]] then it is negative result.
* In a positive result, it is only possible to grasp a [[lump]] of [[tissue]].
 
|
* MRI offers strong qualitative and quantitative parameters in the diagnosis of [[lipedema]] <ref name="pmid9412843">{{cite journal| author=Dimakakos PB, Stefanopoulos T, Antoniades P, Antoniou A, Gouliamos A, Rizos D| title=MRI and ultrasonographic findings in the investigation of lymphedema and lipedema. | journal=Int Surg | year= 1997 | volume= 82 | issue= 4 | pages= 411-6 | pmid=9412843 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9412843  }}</ref>
|-
![[Myxedema]]
|
* History of untreated [[hypothyroidism]].
* Infiltration of the skin with [[Glycosaminoglycan|glycosaminoglycans]] with associated water retention.
|Chronic
| +
| -
|Bilateral
| -
| +
([[hypothyroidism]] )
|
* [[Pretibial myxedema]]
|
* [[Thyroid function tests|Thyroid function tests.]]
|-
!([[Cellulitis]]-[[Erysipelas|erysipelas-]]<nowiki/>[[skin abscess]])
|
* Acute painful [[swelling]]
* [[Fever]]
|Acute
| +
| +
|Unilateral
| -
| -
|
* [[Tenderness]], hotness, and may be fluctuation if [[abscess]] formed.
* [[Lymphangitis]] in nearby [[Lymph node|lymph nodes]].
* [[Toxemia]] and [[fever]] in severe cases.
* [[Cellulitis]] involves the deeper [[dermis]] and [[erysipelas]] involves the upper dermis.<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }}</ref>
|
* Usually it doesn't need any laboratory tests to diagnose.<ref name="pmid27434444">{{cite journal| author=Raff AB, Kroshinsky D| title=Cellulitis: A Review. | journal=JAMA | year= 2016 | volume= 316 | issue= 3 | pages= 325-37 | pmid=27434444 | doi=10.1001/jama.2016.8825 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27434444  }}</ref>
* [[Blood cultures]] are warranted for patients in the following circumstances:<ref name="pmid10834819">{{cite journal| author=Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY| title=Cellulitis complicating lymphoedema. | journal=Eur J Clin Microbiol Infect Dis | year= 2000 | volume= 19 | issue= 4 | pages= 294-7 | pmid=10834819 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10834819  }}</ref>
# [[Toxicity|Systemic toxicity]]
# Extensive [[skin]] or [[soft tissue]] involvement
# Underlying [[comorbidities]]
# persistent [[cellulitis]]
* In patients with recurrent [[cellulitis]], serologic ''testing for [[beta-hemolytic streptococci]]'' is a good diagnostic tool''.''<ref name="pmid4005155">{{cite journal| author=Leppard BJ, Seal DV, Colman G, Hallas G| title=The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. | journal=Br J Dermatol | year= 1985 | volume= 112 | issue= 5 | pages= 559-67 | pmid=4005155 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4005155  }}</ref>
|-
!Other causes of [[generalized edema]]
|
* History of chronic general condition (cardiac-liver-renal)
|Chronic
| -
| -
|Bilateral
| -
|<nowiki>+</nowiki>
|
|
* According to the primary cause ( Echo- [[LFTs]]- RFT)
|}
 
Shown below is a list of conditions that can mimic DVT.
*Venous
**Superficial [[thrombophlebitis]]
**[[Post-thrombotic syndrome]]
**[[Chronic venous insufficiency]]
**Venous obstruction
 
*Other
**[[Cellulitis]]
**Torn [[gastrocnemius muscle]]
**Fracture
**[[Hematoma]]
**Acute arterial ischaemia
**[[Lymphoedema]]
**[[Hypoproteinemia]] (for example, [[cirrhosis]], [[nephrotic syndrome]])
** Muscle tear or leg strain
** Leg swelling in a paralyzed limb
**[[Lymphangitis]] or lymph obstruction
** Popliteal/[[Baker's cyst]]
** [[Cellulitis]]
** Knee abnormality


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Hematology]]
[[Category:Angiology]]
[[Category:Emergency medicine]]
[[Category:Vascular surgery]]
[[Category:Up-To-Date]]
[[Category:Cardiovascular diseases]]

Latest revision as of 16:53, 7 March 2018

<figure-inline><figure-inline></figure-inline></figure-inline>

Resident
Survival
Guide

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet

Deep Vein Thrombosis Microchapters

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Differentiating Deep vein thrombosis from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

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Assessment of Clinical Probability and Risk Scores

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Overview

Deep vein thrombosis DVT is characterized by pain and swelling of the limb, which are not specific symptoms. There are other conditions that can mimic DVT such as muscle strain or muscle tear, immobilization that led to leg swelling, lymphedema, lymphangitis, chronic venous insufficiency, or cellulitis.

Differential Diagnosis

Deep vein thrombosis must be differentiated from other causes of lower limb edema like chronic venous insufficiency, lymphatic filariasis, lipedema, myxedema, cellulitis and causes of generalized edema.

Diseases Symptoms Signs Gold standard Investigation to diagnose
History Onset Pain Fever Laterality Scrotal swelling Symptoms of primary disease
Acute deep venous thrombosis Acute + - Unilateral - May be associated with primary disease mandates recumbency for long duration
Lymphatic filariasis
  • History of living in endemic area or travelling to it
 Chronic + + Bilateral + -

Preparing blood smears

  • Thick smears
  1. Thick smears consist of a thick layer of dehemoglobinized (lysed) red blood cells (RBCs).
  2. Thick smears allow a more efficient detection of parasites (increased sensitivity).
  • Thin smears consist of blood spread in a layer such that the thickness decrease.

By the ultrasound, the following findings can be observed:

  • Dilated lymphatic channels
  • Living worms tend to be in motion which called "filarial dance" sign.
Chronic venous insufficiency Chronic + - Bilateral +

(If congenial)

-
  • Typical varicose veins
  • Skin change distribution correlate with varicose veins sites in the medial side of ankle and leg
  • Reduction of swelling with limb elevation.
Lipedema Chronic + - Bilateral - -
  • Tender with palpation
  • Negative Semmer sign to differentiate from lymphedema.[3]
  • Pinching the skin on the upper surface of the toes. If it is possible to grasp a thin fold of tissue then it is negative result.
  • In a positive result, it is only possible to grasp a lump of tissue.
  • MRI offers strong qualitative and quantitative parameters in the diagnosis of lipedema [4]
Myxedema Chronic + - Bilateral - +

(hypothyroidism )

(Cellulitis-erysipelas-skin abscess) Acute + + Unilateral - -
  • Usually it doesn't need any laboratory tests to diagnose.[6]
  • Blood cultures are warranted for patients in the following circumstances:[7]
  1. Systemic toxicity
  2. Extensive skin or soft tissue involvement
  3. Underlying comorbidities
  4. persistent cellulitis
Other causes of generalized edema
  • History of chronic general condition (cardiac-liver-renal)
 Chronic - - Bilateral - +
  • According to the primary cause ( Echo- LFTs- RFT)

Shown below is a list of conditions that can mimic DVT.

References

  1. ↑ Goodacre S, Sutton AJ, Sampson FC (2005). "Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis". Ann Intern Med. 143 (2): 129–39. PMID 16027455. Review in: ACP J Club. 2006 Mar-Apr;144(2):46-7 Review in: Evid Based Med. 2006 Apr;11(2):56
  2. ↑ Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S; et al. (2010). "Lipedema: an inherited condition". Am J Med Genet A. 152A (4): 970–6. doi:10.1002/ajmg.a.33313. PMID 20358611.
  3. ↑ Trayes KP, Studdiford JS, Pickle S, Tully AS (2013). "Edema: diagnosis and management". Am Fam Physician. 88 (2): 102–10. PMID 23939641.
  4. ↑ Dimakakos PB, Stefanopoulos T, Antoniades P, Antoniou A, Gouliamos A, Rizos D (1997). "MRI and ultrasonographic findings in the investigation of lymphedema and lipedema". Int Surg. 82 (4): 411–6. PMID 9412843.
  5. ↑ Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
  6. ↑ Raff AB, Kroshinsky D (2016). "Cellulitis: A Review". JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.
  7. ↑ Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY (2000). "Cellulitis complicating lymphoedema". Eur J Clin Microbiol Infect Dis. 19 (4): 294–7. PMID 10834819.
  8. ↑ Leppard BJ, Seal DV, Colman G, Hallas G (1985). "The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas". Br J Dermatol. 112 (5): 559–67. PMID 4005155.
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