Myxedema coma differential diagnosis: Difference between revisions
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![[Myxedema]] | ![[Myxedema]] | ||
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* History of untreated [[hypothyroidism]] | * History of untreated [[hypothyroidism]] | ||
* Infiltration of the [[skin]] with [[Glycosaminoglycan|glycosaminoglycans]] with associated [[water retention]] | * Infiltration of the [[skin]] with [[Glycosaminoglycan|glycosaminoglycans]] with associated [[water retention]] | ||
|Chronic | |Chronic | ||
| + | | + | ||
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* [[Pretibial myxedema]] | * [[Pretibial myxedema]] | ||
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* [[Thyroid function tests|Thyroid function tests | * [[Thyroid function tests|Thyroid function tests]] | ||
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* Scrotal [[elephantiasis]] | * Scrotal [[elephantiasis]] | ||
* [[Lymphadenopathy|Lymphadenopathies]] | * [[Lymphadenopathy|Lymphadenopathies]] | ||
* [[Rhonchi]] may be present in patients with [[Pulmonary]] tropical [[eosinophilia]] syndrome | * [[Rhonchi]] may be present in patients with [[Pulmonary]] tropical [[eosinophilia]] syndrome | ||
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Preparing blood smears | |||
* Thick smears | * Thick smears | ||
** Thick smears consist of a thick layer of dehemoglobinized (lysed) [[Red blood cell|red blood cells]] ([[RBCs]]) | |||
* Thin smears consist of [[blood]] spread in a layer such that the thickness decrease | ** 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|lymphatic channels]] | * Dilated [[Lymphatic|lymphatic channels]] | ||
* Living worms tend to be in motion which called "[[filarial]] dance" sign. | * Living worms tend to be in motion which called "[[filarial]] dance" sign. | ||
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* History of untreated [[varicose veins]] | * History of untreated [[varicose veins]] | ||
* Painful bilateral [[lower limb]] [[swelling]] that increases with standing and decreases by rest and [[leg]] elevation | * Painful bilateral [[lower limb]] [[swelling]] that increases with standing and decreases by rest and [[leg]] elevation | ||
|Chronic | |Chronic | ||
|<nowiki>+</nowiki> | |<nowiki>+</nowiki> | ||
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* Typical varicose veins | * Typical varicose veins | ||
* [[Skin]] change distribution correlate with varicose veins sites in the medial side of [[ankle]] and [[leg]] | * [[Skin]] change distribution correlate with varicose veins sites in the medial side of [[ankle]] and [[leg]] | ||
* Reduction of [[swelling]] with limb elevation | * Reduction of [[swelling]] with limb elevation | ||
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* [[Duplex ultrasound]] will demonstrate typical findings of [[Venous insufficiency|venous valvular insufficiency]] | * [[Duplex ultrasound]] will demonstrate typical findings of [[Venous insufficiency|venous valvular insufficiency]] | ||
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* Dilated [[superficial veins]] | * 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> | * 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 | * Calf pain on passive [[dorsiflexion]] of the [[foot]] ([[Homan's sign]]) isn't realiable sign | ||
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![[Lipedema]] | ![[Lipedema]] | ||
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* Family history especially in women; [[X-linked dominant]] or [[autosomal dominant]] condition | * 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]] | * Abnormal deposition of fat and [[edema]] and [[easy bruising]] | ||
|Chronic | |Chronic | ||
| + | | + | ||
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* Tender with [[palpation]] | * Tender with [[palpation]] | ||
* Negative | * 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]] | * 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]]. | * In a positive result, it is only possible to grasp a [[lump]] of [[tissue]]. | ||
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| - | | - | ||
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* [[Tenderness]], hotness, and may be fluctuation if [[abscess]] formed | * [[Tenderness]], hotness, and may be fluctuation if [[abscess]] formed | ||
* [[Lymphangitis]] in nearby [[Lymph node|lymph nodes]] | * [[Lymphangitis]] in nearby [[Lymph node|lymph nodes]] | ||
* [[Toxemia]] and [[fever]] in severe cases | * [[Toxemia]] and [[fever]] in severe cases | ||
* [[Cellulitis]] involves the deeper [[dermis]] and [[erysipelas]] involves the upper [[dermis]] | * [[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> | ||
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* Usually it doesn't need any laboratory tests to diagnose | * 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> | * [[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]] | # [[Toxicity|Systemic toxicity]] | ||
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# Underlying [[comorbidities]] | # Underlying [[comorbidities]] | ||
# Persistent [[cellulitis]] | # Persistent [[cellulitis]] | ||
* In patients with recurrent [[cellulitis]], [[Serology|serologic]] ''testing for [[beta-hemolytic streptococci]]'' is a good diagnostic tool | * In patients with recurrent [[cellulitis]], [[Serology|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]] | !Other causes of [[generalized edema]] | ||
Revision as of 00:39, 26 October 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Differential Diagnosis
Myxedema must be differentiated from other causes of lower limb edema like chronic venous insufficiency, acute deep venous thrombosis, lipedema, lymphatic filariasis, cellulitis and causes of generalized edema.
| Diseases | History | Symptoms | Signs | Gold standard Investigation to diagnose | |||||
|---|---|---|---|---|---|---|---|---|---|
| Onset | Pain | Fever | Laterality | Scrotal swelling | Symptoms of primary disease | ||||
| Myxedema |
|
Chronic | + | - | Bilateral | - | + | ||
| Lymphatic filariasis |
|
Chronic | + | + | Bilateral | + | - |
|
Preparing blood smears
By the ultrasound, the following findings can be observed:
|
| Chronic venous insufficiency |
|
Chronic | + | - | Bilateral | +
(If congenial) |
- |
| |
| Acute deep venous thrombosis | Acute | + | - | Unilateral | - | May be associated with primary disease mandates recumbency for long duration |
|
| |
| Lipedema |
|
Chronic | + | - | Bilateral | - | - |
|
|
| (Cellulitis-erysipelas-skin abscess) | Acute | + | + | Unilateral | - | - |
|
| |
| Other causes of generalized edema | Chronic | - | - | Bilateral | - | + |
| ||
References
- ↑ 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
- ↑ 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.
- ↑ Trayes KP, Studdiford JS, Pickle S, Tully AS (2013). "Edema: diagnosis and management". Am Fam Physician. 88 (2): 102–10. PMID 23939641.
- ↑ 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.
- ↑ 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.
- ↑ Raff AB, Kroshinsky D (2016). "Cellulitis: A Review". JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.
- ↑ 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.
- ↑ 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.