Wheeze differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: John Fani Srour, M.D.

Overview

The differential diagnosis of wheezing is wide, and the cause of wheezing in a given patient is determined by considering the characteristics of the wheezes and the historical and clinical findings made by the examining physician.

Complete Differential Diagnosis of the Causes of Wheeze

(In alphabetical order)

• Abnormal arytenoid movement
• Allergic bronchopulmonary aspergillosis ABPA
• Alpha 1-Antitrypsin Deficiency
• Amyloid deposition
• Anaphylaxis
• Angioedema
• Aspergillosis including aspergilloma and ABPA
• Aspiration(foreign particles or foods)
• Asthma including status asthmaticus
• Benign airway tumors including:
  • Bronchial adenomata syndrome
  • Unknown (hamartoma, clear cell, teratoma)
  • Epithelial (papilloma, polyps)
  • Mesodermal (fibroma, lipoma, leiomyoma, chondroma, granular cell tumor, sclerosing hemangioma)
  • Other (myofibroblastic tumor, xanthoma, amyloid, mucosa-associated lymphoid tumor)
• Bronchiectasis
• Bronchiolitis (a common childhood disease)
• Bronchiolitis obliterans
• Bronchitis (usually viral, bacterial only in patients with tracheostomy or endotracheal intubation)
  • influenza A and B
  • parainfluenza
  • coronavirus (types 1-3)
  • rhinovirus
  • respiratory syncytial virus
  • human metapneumovirus
  • Other:
    • Mycoplasma pneumoniae
    • Chlamydophila pneumoniae
    • Pertussis
• Bronchopulmonary dysplasia
• Byssinosis - cotton duct
• Carcinoid syndrome
• Cardiac asthma (including cardiogenic pulmonary edema)
• Cardiomegaly (severe cardiomegaly)
• Chemical poisoning (more than 50 substances have been linked to wheezing)
• Chondromalacia
• Chronic obstructive pulmonary disease: Chronic bronchitis and Emphysema
• Cold induced wheezing (Paediatrics)
• Ciliary dyskinesia-bronchiectasis
• Congenital abnormalities affecting the bronchial tree
• Cricoarytenoid arthritis
• Cystic fibrosis
• Descending aortic aneurysm
• Dialyzer hypersensitivity syndrome
• Esophageal foreign body
• Exercise-induced asthma
• Extrinsic allergic alveolitis
• Food allergies: numerous including:
  • Peanut Allergy
• Gastroesophageal Reflux Disease (with aspiration)
• Graft-versus-host disease
• Hay fever
• Heart failure (see cardiogenic pulmonary edema and cardiac asthma)
• Hemorrhage, pulmonary
• Hypertrophied tonsils
• Immunodeficiency
• Infection (pneumonia)
• Interstitial lung disease
• Intrathoracic goiter
• Klebsiella rhinoscleroma
• Laryngeal edema
• Laryngocele
• Laryngostenosis
• Laryngotracheobronchitis
• Lymphadenopathy with large lymphnodes compressing the tracheal tree.
• Lymphangitic carcinomatosis
• Malignancy (bronchogenic)
  • Squamous cell carcinoma with variants: papillary, clear cell, small cell, basaloid
  • Small cell carcinoma
  • Adenocarcinoma
    • Acinar
    • Papillary
    • Bronchioloalveolar carcinoma
      • Non-mucinous (Clara cell/type II pneumocyte type)
      • Mucinous (Goblet cell type)
      • Mixed mucinous and non-mucinous (Clara cell/type II pneumocyte/goblet cell type) or indeterminate
    • Solid adenocarcinoma with mucin formation
    • Mixed
    • Variants: well-differentiated fetal adenocarcinoma, mucinous ("colloid"), mucinous cystadenocarcinoma, signet ring, clear cell
  • Large cell carcinoma with variants: large cell neuroendocrine carcinoma, combined large cell neuroendocrine carcinoma, basaloid carcinoma, lymphoepithelioma-like carcinoma, clear cell carcinoma, large cell carcinoma with rhaboid phenotype
  • Adenosquamous carcinoma
  • Carcinomas with pleomorphic, sarcomatoid, or sarcomatous elements
    • Carcinomas with spindle and/or giant cells
    • Pleomorphic carcinoma
    • Spindle cell carcinoma
    • Giant cell carcinoma
    • Carcinosarcoma
    • Blastoma (Pulmonary blastoma)
  • Carcinoid tumor
    • Typical carcinoid
    • Atypical carcinoid
  • Carcinomas of salivary gland type
    • Mucoepidermoid carcinoma
    • Adenoid cystic carcinoma
  • Unclassified carcinoma
  • Mastocytosis
  • Mendelson's syndrome (aspiration pneumonitis)
• Medication-induced bronchoconstriction
  • ACE inhibitors ( cough or rarely Angioneurotic edema and wheeze)
  • Sotalol
  • Adenosine
  • Beta blockers: Common; usually occurs in patients with asthma or COPD; 1-selective agents, labetalol, esmolol, and pindolol are better tolerated than nonselective agents.
  • Dipyridamole (IV form only)
  • Protamine
  • NSAIDs includign aspirin
  • Marijuana (chronic use)
• Milk allergy
• Mobile supraglottic soft tissue
• Obesity
• Parasitic infections
  • Ascariasis
  • Hookworm
  • Paragonimiases - lung infection
  • Strongyloidiasis
  • Toxocariasis
• Paroxysmal vocal cord motion
• Postextubation granuloma
• Postlobectomy bronchial torsion
• Postnasal drip syndrome
• Postradiation stenosis
• Primary ciliary dyskinesia
• Psychogenic wheezing
• Pulmonary edema (cardiogenic or non-cardiogenic)
• Pulmonary embolism
• Pulmonary eosinophilia
• Relapsing polychondritis
• Retained foreign body (trachea or esophagus)
• Retropharyngeal abscess
• Right sided aortic arch
• Sinusitis ( chronic sinusitis )
• Supraglottitis
• Tracheal stenosis
• Tracheobronchitis
• Tracheobronchomegaly
• Tracheobronchopathia osteoplastica : a rare, benign condition and is characterized by the presence of bony and cartilaginous nodules in the tracheal and bronchial mucosa.
• Tracheomalacia
• Tuberculosis, Pulmonary
• Vascular compression and rings ( Aberrant subclavian artery abnormality )
• Vocal cord dysfunction
• Vocal cord hematoma
• Vocal cord paralysis (bilateral paralysis)
• Wegener's granulomatosis

Complete Differential Diagnosis of the Causes of Wheeze

(By organ system)

Cardiovascular	Cardiac asthma ( pulmonary edema), Cardiomegaly, Descending aortic aneurysm, Pulmonary edema Pulmonary embolism, Right sided aortic arch, Vascular compression/ rings, Heart failure
Chemical / poisoning	Dialyzer hypersensitivity syndrome, Food allergies, Peanut Allergy, Chemical poisoning
Dermatologic	No underlying causes
Drug Side Effect	Medication-induced bronchoconstriction, ACE inhibitors, Sotalol ,Adenosine, Beta blockers, Dipyridamole, Protamine, NSAIDs, Aspirin, Marijuana
Ear Nose Throat	Aspiration(foreign particles or foods), Bilateral vocal cord paralysis, Hypertrophied tonsils, Intrathoracic goiter, Laryngeal edema, Laryngocele, Laryngostenosis, Laryngotracheobronchitis, Mobile supraglottic soft tissue, Paroxysmal vocal cord motion, Postextubation granuloma, Postlobectomy bronchial torsion, Postnasal drip syndrome, Postradiation stenosis, Retropharyngeal abscess, Supraglottitis, Vocal cord dysfunction, Vocal cord hematoma, Sinusitis
Endocrine	Intrathoracic goiter, Obesity,
Environmental	asthma, Byssinosis, Hay fever
Gastroenterologic	Gastroesophageal Reflux Disease
Genetic	Cystic fibrosis, Milk allergy, Obesity, Primary ciliary dyskinesia, Vascular compression/ rings, Alpha 1-Antitrypsin Deficiency, Ciliary dyskinesia-bronchiectasis,
Hematologic	Lymphadenopathy
Iatrogenic	Aspiration(foreign particles or foods), Esophageal foreign body, Mendelson's syndrome (aspiration pneumonitis),
Infectious Disease	Allergic bronchopulmonary aspergillosis, Cold induced wheezing, Bronchitis, Bronchiolitis, pneumonia, Lymphadenopathy, Retropharyngeal abscess, Tuberculosis, Ascariasis, Hookworm, Paragonimiases - lung infection, Strongyloidiasis, Toxocariasis, Aspergillosis
Musculoskeletal / Ortho	Cricoarytenoid arthritis,
Neurologic	No underlying causes
Nutritional / Metabolic	Obesity
Obstetric/Gynecologic	No underlying causes
Oncologic	Carcinoid syndrome, Lymphadenopathy, Lymphangitic carcinomatosis, Malignancy (bronchogenic tumors), Bronchial adenomata syndrome, Mastocytosis
Opthalmologic	No underlying causes
Overdose / Toxicity	chemical poisoning
Psychiatric	Psychogenic wheezing
Pulmonary	Bronchiectasis, Bronchiolitis, Bronchiolitis obliterans, Bronchitis, Bronchopulmonary dysplasia, Carcinoid syndrome, Chronic obstructive pulmonary disease: Chronic bronchitis and Emphysema, Cold induced wheezing, Cystic fibrosis, Pulmonary hemorrhage, pneumonia, Interstitial lung disease, Postlobectomy bronchial torsion, Postradiation stenosis, Primary ciliary dyskinesia, Pulmonary edema, Pulmonary embolism, Tracheal stenosis, Tracheobronchitis, Tracheobronchomegaly, Tracheomalacia, Wegener's granulomatosis, Pulmonary eosinophilia, Tuberculosis, Alpha 1-Antitrypsin Deficiency, Extrinsic allergic alveolitis, Bronchial adenomata syndrome, Ciliary dyskinesia-bronchiectasis, Tracheobronchopathia osteoplastica, Aspergillosis
Renal / Electrolyte	No underlying causes
Rheum / Immune / Allergy	Allergic bronchopulmonary aspergillosis, Anaphylaxis, Angioedema, Asthma, Cricoarytenoid arthritis, Immunodeficiency, Interstitial lung disease, Lymphadenopathy, Milk allergy, Relapsing polychondritis, Wegener's granulomatosis, Pulmonary eosinophilia, Extrinsic allergic alveolitis, Graft-versus-host disease, Hay fever, Mastocytosis,
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	Amyloid deposition, Tracheobronchopathia osteochondroplastica

Inflamed airways and bronchoconstriction in asthma. Airways narrowed as a result of the inflammatory response cause wheezing.

References

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