Pulmonary embolism differential diagnosis: Difference between revisions

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Revision as of 19:36, 11 October 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

Pulmonary embolism must be distinguished from other life-threatening causes of chest pain including acute myocardial infarction, aortic dissection, and pericardial tamponade, as well as a large list of non-life-threatening causes of chest discomfort and shortness of breath.

Differential Diagnosis

Differential Diagnosis Based on Symptoms

Pulmonary embolism (PE) should be differentiated from other diseases presenting with chest pain, shortness of breath and tachypnea. The differentials include the following:

Diseases	CT scan and MRI	EKG	Chest X-ray	Tachypnea	Tachycardia	Fever	Chest Pain	Hemoptysis	Dyspnea on Exertion	Wheezing	Chest Tenderness	Nasalopharyngeal Ulceration	Carotid Bruit	Past medical history	Other Findings
Diseases	Diagnostic tests			Physical Examination			Symptoms							Past medical history	Other Findings
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)	S1Q3T3 pattern representing acute right heart strain	Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign	✔	✔	✔ (Low grade)	✔	✔ (In case of massive PE)	✔	-	-	-	-	Hypercoagulating conditions (Factor V Leiden, thrombophilia, deep vein thrombosis, immobilization, malignancy, pregnancy)	May be associated with metabolic alkalosis and syncope
Congestive heart failure	On CT scan: Mediastinal lymphadenopathy hazy mediastinal fat On MRI: Abnormality of cardiac chambers (hypertrophy, dilation) Delayed enhancement MRI may help characterize the myocardial tissue (fibrosis) Late enhancement of contrast in conditions such as myocarditis, sarcoidosis, amyloidoisis, Anderson-Fabry's disease, Chagas' disease)	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	Cardiomegaly	✔	✔	✔	-	-	✔	-	-	-	-	Previous myocardial infarction Hypertension (systemic and pulmonary) Cardiac arrythmias Viral infections (myocarditis) Congenital heart defects	Right heart faliure ssociated with: Hepatomegaly Positive hepatojugular reflex Increased jugular venous pressure Peripheral edema Left heart faliure associated with: Pulmonary edema Eventual right heart faliure

Life Threatening Differential Diagnosis

Common Differential Diagnosis in Outpatients

Among outpatients presenting with dyspnea, <4 % are diagnosed with PE.^[1] Common differential diagnoses include:^[1]

Acute heart failure
Pneumonia
Chronic obstructive pulmonary disease exacerbation

Complete List of Differential Diagnosis

Acute coronary syndrome
Acute heart failure^[1]
Asthma acute exacerbation
Acute respiratory distress syndrome
Anemia
Angina pectoris
Anxiety disorders
Aortic stenosis
Atrial fibrillation (diagnosis and management)
Bronchitis
Cardiogenic shock
Cardiac tamponade
Chronic obstructive pulmonary disease exacerbation^[1]
Community acquired pneumonia^[1]
Cor pulmonale
Costochondritis
Dilated cardiomyopathy
Distributive shock
Emphysema
Fat embolism
Hemorrhagic shock
Herpes zoster
Hyperventilation
Mediastinitis
Mitral stenosis
Musculoskeletal pain
Myocardial infarction
Myocardial ischemia
Myocarditis
Noncardiogenic pulmonary edema
Pericarditis
Pleuritis
Pneumonia
Pneumothorax
Pulmonary hypertension, primary
Pulmonary hypertension, secondary
Restrictive cardiomyopathy
Rib fracture
Salicylate intoxication
Septic shock
Silicone pulmonary embolism^[2]
Sudden cardiac death
Superior vena cava syndrome
Syncope
Toxic shock syndrome
Trauma to the chest
Unstable angina

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 Squizzato A, Luciani D, Rubboli A, Di Gennaro L, Gennaro LD, Landolfi R; et al. (2013). "Differential diagnosis of pulmonary embolism in outpatients with non-specific cardiopulmonary symptoms". Intern Emerg Med. 8 (8): 695–702. doi:10.1007/s11739-011-0725-1. PMID 22094406.
↑ Restrepo CS, Artunduaga M, Carrillo JA, Rivera AL, Ojeda P, Martinez-Jimenez S; et al. (2009). "Silicone pulmonary embolism: report of 10 cases and review of the literature". J Comput Assist Tomogr. 33 (2): 233–7. doi:10.1097/RCT.0b013e31817ecb4e. PMID 19346851.

Template:WH Template:WS

[pmid22094406-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 Squizzato A, Luciani D, Rubboli A, Di Gennaro L, Gennaro LD, Landolfi R; et al. (2013). "Differential diagnosis of pulmonary embolism in outpatients with non-specific cardiopulmonary symptoms". Intern Emerg Med. 8 (8): 695–702. doi:10.1007/s11739-011-0725-1. PMID 22094406.

[pmid19346851-2] Restrepo CS, Artunduaga M, Carrillo JA, Rivera AL, Ojeda P, Martinez-Jimenez S; et al. (2009). "Silicone pulmonary embolism: report of 10 cases and review of the literature". J Comput Assist Tomogr. 33 (2): 233–7. doi:10.1097/RCT.0b013e31817ecb4e. PMID 19346851.

[1]

[2]

@@ Line 18: / Line 18: @@
 ! rowspan="2" |<small>Diseases</small>
 ! colspan="3" |<small>Diagnostic tests</small>
-! colspan="4" |<small>Physical Examination</small>
+! colspan="3" |<small>Physical Examination</small>
-| colspan="5" |<small>Symptoms
+| colspan="7" |<small>Symptoms
 ! colspan="1" rowspan="2" |<small>Past medical history</small>
 ! rowspan="2" |<small>Other Findings</small>
@@ Line 45: / Line 45: @@
 ** No contrast seen distal to obstruction
 ** Polo-mint sign (partial filling defect surrounded by contrast)
-| style="background: #F5F5F5; padding: 5px;" |Identifies causative [[bacteria]]
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |Imaging and culture
+* S1Q3T3 pattern representing acute right heart strain
-| style="background: #F5F5F5; padding: 5px;" | ✔
+| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |[[Flank pain|Flank]] or [[costovertebral angle]]
+* Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign
 | style="background: #F5F5F5; padding: 5px;" |✔
 | 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;" |✔
+| style="background: #F5F5F5; padding: 5px;" |✔ (In case of massive PE)
+| 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;" |
+*Hypercoagulating conditions (Factor V Leiden, thrombophilia, deep vein thrombosis, immobilization, malignancy, pregnancy)
+| style="background: #F5F5F5; padding: 5px;" |
+* May be associated with metabolic alkalosis and syncope
+|-
+| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Congestive heart failure]]
+|style="background: #F5F5F5; padding: 5px;" |
+*On CT scan:
+** Mediastinal lymphadenopathy
+** hazy mediastinal fat
+*On MRI:
+** Abnormality of cardiac chambers (hypertrophy, dilation)
+** Delayed enhancement MRI may help characterize the myocardial tissue (fibrosis)
+** Late enhancement of contrast in conditions such as myocarditis, sarcoidosis, amyloidoisis, Anderson-Fabry's disease, Chagas' disease)
+|style="background: #F5F5F5; padding: 5px;" |
+*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
+|style="background: #F5F5F5; padding: 5px;" |
+*Cardiomegaly
+| 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;" |
+*Previous myocardial infarction
+*Hypertension (systemic and pulmonary)
+*Cardiac arrythmias
+*Viral infections (myocarditis)
+*Congenital heart defects
+| style="background: #F5F5F5; padding: 5px;" |
+*Right heart faliure ssociated with:
+**Hepatomegaly
+**Positive hepatojugular reflex
+**Increased jugular venous pressure
+**Peripheral edema
+*Left heart faliure associated with:
+**Pulmonary edema
+**Eventual right heart faliure
+|}
 ===Life Threatening Differential Diagnosis===
 * [[Acute myocardial infarction]]