Pulmonary embolism differential diagnosis: Difference between revisions

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| <figure-inline>[[File:Siren.gif|link=Pulmonary embolism resident survival guide|41x41px]]</figure-inline>|| <br> || <br>
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| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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** Intra-luminal filling defect  
** Intra-luminal filling defect  
*On [[MRI]]:
*On [[MRI]]:
** Narrowing of involved vessel
** Narrowing of involved [[Blood vessel|vessel]]
** No contrast seen distal to obstruction
** No contrast seen distal to [[obstruction]]
** Polo-mint sign (partial filling defect surrounded by contrast)
** Polo-mint sign (partial filling defect surrounded by contrast)
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* S1Q3T3 pattern representing acute right heart strain
* [[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain
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* Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign
* [[Fleischner sign]] (enlarged pulmonary artery), [[Hampton's hump|Hampton hump]], [[Westermark's sign]]
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*Hypercoagulating conditions (Factor V Leiden, thrombophilia, deep vein thrombosis, immobilization, malignancy, pregnancy)
*Hypercoagulating conditions ([[Factor V Leiden]], [[thrombophilia]], [[deep vein thrombosis]], immobilization, [[malignancy]], [[pregnancy]])
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* May be associated with metabolic alkalosis and syncope
* May be associated with [[metabolic alkalosis]] and [[syncope]]
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| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Congestive heart failure]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Congestive heart failure]]
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*On CT scan:
*On [[Computed tomography|CT scan]]:
** Mediastinal lymphadenopathy
** [[Mediastinal lymphadenopathy]]
** hazy mediastinal fat
** Hazy [[mediastinal]] fat
*On MRI:
*On [[Magnetic resonance imaging|MRI]]:
** Abnormality of cardiac chambers (hypertrophy, dilation)
** Abnormality of [[cardiac]] chambers ([[Hypertrophy (medical)|hypertrophy]], dilation)
** Delayed enhancement MRI may help characterize the myocardial tissue (fibrosis)
** Delayed enhancement [[MRI]] may help characterize the [[myocardial]] [[Tissue (biology)|tissue]] ([[fibrosis]])
** Late enhancement of contrast in conditions such as myocarditis, sarcoidosis, amyloidoisis, Anderson-Fabry's disease, Chagas' disease)
** Late enhancement of contrast in conditions such as [[myocarditis]], [[sarcoidosis]], [[amyloidosis]], [[Anderson-Fabry disease|Anderson-Fabry]]'s disease, [[Chagas disease]])
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*Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
*Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
**SV1 or SV2 + RV5 or RV6 ≥3.5 mV
**[[S wave|S]]V1 or [[S wave|S]]V2 + [[R wave|R]]V5 or [[R wave|R]]V6 ≥3.5 mV
**Total QRS amplitude in each of the limb leads ≤0.8 mV
**Total [[QRS complex|QRS]] amplitude in each of the limb leads ≤0.8 mV
** R/S ratio <1 in lead V4
** [[R wave|R]]/[[S wave|S]] ratio <1 in lead V4
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*Cardiomegaly
*[[Cardiomegaly]]
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*Previous myocardial infarction
*Previous [[myocardial infarction]]
*Hypertension (systemic and pulmonary)
*[[Hypertension]] ([[Systemic hypertension|systemic]] and [[Pulmonary hypertension|pulmonary]])
*Cardiac arrythmias
*[[Cardiac arrhythmia|Cardiac arrythmias]]
*Viral infections (myocarditis)
*[[Viral]] infections ([[myocarditis]])
*Congenital heart defects
*[[Congenital heart disease|Congenital heart defects]]
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*Right heart faliure ssociated with:
*[[Right heart failure]] associated with:
**Hepatomegaly  
**[[Hepatomegaly]]
**Positive hepatojugular reflex
**Positive hepato-jugular reflex
**Increased jugular venous pressure
**Increased [[jugular venous pressure]]
**Peripheral edema  
**[[Peripheral edema]]
*Left heart faliure associated with:
*[[Left heart failure]] associated with:
**Pulmonary edema
**[[Pulmonary edema]]
**Eventual right heart faliure
**Eventual [[right heart failure]]
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Percarditis]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Percarditis]]
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*On contrast enhanced CT scan:
*On contrast enhanced [[Computed tomography|CT scan]]:
**Enhancement of the pericardium (due to inflammation)
**Enhancement of the [[pericardium]] (due to [[inflammation]])
**Pericardial effusion
**[[Pericardial effusion]]
**Pericardial calcification
**[[Pericardial calcification]]
*On gadolinium-enhanced fat-saturated T1-weighted MRI:
*On [[gadolinium]]-enhanced fat-saturated [[Magnetic resonance imaging|T1-weighted MRI]]:
**Pericardial enhancement (due to inflammation)
**[[Pericardial]] enhancement (due to [[inflammation]])
**Pericardial effusion
**[[Pericardial effusion]]
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*ST elevation
*ST elevation
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*Infections:
*Infections:
**Viral (Coxsackie virus, Herpes virus, Mumps virus, HIV)
**[[Viral]] (Coxsackie virus, [[Herpes simplex virus|Herpes virus]], [[Mumps virus]], [[Human Immunodeficiency Virus (HIV)|HIV]])
**Bacteria (Mycobacterium tuberculosis-common in developing countries)
**[[Bacteria]] ([[Mycobacterium tuberculosis]]-common in developing countries)
**Fungal (Histoplasmosis)
**[[Fungal]] ([[Histoplasmosis]])
*Idiopathic in a large number of cases
*Idiopathic in a large number of cases
*Autoimmune
*[[Autoimmune]]
*Uremia
*[[Uremia]]
*Malignancy
*[[Malignancy]]
*Previous myocardial infarction
*Previous [[myocardial infarction]]
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*May be clinically classified into:
*May be clinically classified into:
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumonia]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumonia]]
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**On CT scan: (not generally indicated)
*On [[Computed tomography|CT scan]]: (not generally indicated)
*Consolidation (alveolar/lobar pneumonia)
**[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar pneumonia)
*Peribronchial nodules (bronchopneumonia)
**Peribronchial [[nodules]] ([[bronchopneumonia]])
*Ground-glass opacity (GGO)
**[[Ground glass opacification on CT|Ground-glass opacity]] (GGO)
*Abscess
**[[Abscess]]
*Pleural effusion
**[[Pleural effusion]]
**On MRI:
**On [[MRI]]:
*Not indicated
*Not indicated
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*Prolonged PR interval  
*Prolonged [[PR interval]]
*Transient T wave inversions
*Transient [[T wave]] inversions
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*Consolidation (alveolar/lobar pneumonia)
*[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar [[pneumonia]])
*Peribronchial nodules (bronchopneumonia)
*Peribronchial [[nodules]] (bronchopneumonia)
*Ground-glass opacity (GGO)
*Ground-glass opacity (GGO)
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*Ill-contact
*Ill-contact
*Travelling
*Travelling
*Smoking
*[[Smoking]]
*Diabetic
*[[Diabetes mellitus|Diabetic]]
*Recent hospitalization
*Recent hospitalization
*Chronic obstructive pulmonary disease
*[[Chronic obstructive pulmonary disease]]
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*Requires sputum stain and culture for diagnosis
*Requires [[Sputum|sputum stain]] and culture for diagnosis
*Empiric management usually started before culture results
*[[Empiric therapy|Empiric management]] usually started before [[Culture collection|culture]] results
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Vasculitis]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Vasculitis]]
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*Alpha 1 antitrypsin deficiency may be associated with hepatomegaly
*Alpha 1 antitrypsin deficiency may be associated with hepatomegaly
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===Life Threatening Differential Diagnosis===
===Life Threatening Differential Diagnosis===

Revision as of 20:56, 13 October 2017

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Resident
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Risk calculators and risk factors for Pulmonary embolism differential diagnosis

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 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) ✔ - - - -
Congestive heart failure
  • 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
 ✔ ✔ ✔ - - ✔ - - - -
Percarditis
  • ST elevation
  • PR depression
  • Large collection of fluid inside the pericardial sac (pericardial effusion)
  • Calcification of pericardial sac
 ✔ ✔ ✔ (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)
Pneumonia ✔ ✔ ✔ ✔ - ✔ ✔ - - -
Vasculitis
  • On CT scan: (Takayasu arteritis)
    • Vessel wall thickening
    • Luminal narrowing of pulmonary artery
    • Masses or nodules (ANCA-associated granulomatous vasculitis)
  • On MRI:

Homogeneous, circumferential vessel wall swelling

  • Right or left bundle-branch block (Churg-Strauss syndrome)
  • Atrial fibrillation (Churg-Strauss syndrome)
  • Non-specific ST segment and T wave changes
  • Nodules
  • Cavitation
 ✔ ✔ ✔ ✔ ✔ ✔ - ✔ ✔ ✔
  • 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 nephtitis and upper airway (nasopharyngeal) destruction
Chronic obstructive pulmonary disease (COPD)
  • On CT scan:
    • Chronic bronchitis may show bronchial wall thickening, scarring with bronchovascular irregularity, fibrosis
    • Emphysema may show alveolar septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe)
    • Giant bubbles
  • ON MRI:
    • Increased diameter of pulmonary arteries
    • Peripheral pulmonary vasculature attentuation
    • Loss of retrosternal airspace due to right ventricular enlargement
    • Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung
  • Multifocal atrial tachycardia (atleast 3 distinct P wave morphologies)
  • Enlarged lung shadows (emphysema)
  • Flattening of diaphragm (emphysema)
 ✔ ✔ - - - ✔ ✔ - - -
  • Smoking
  • Alpha-1 antitrypsin deficiency
  • Increased sputum production (chronic bronhitis)
  • Cough
  • Alpha 1 antitrypsin deficiency may be associated with hepatomegaly

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]

Complete List of Differential Diagnosis

References

  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.
  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.

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