Pulmonary embolism differential diagnosis: Difference between revisions

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| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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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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*On CT scan: (Takayasu arteritis)
*On [[Computed tomography|CT scan]]: ([[Takayasu's arteritis|Takayasu arteritis]])
**Vessel wall thickening
**[[Blood vessel|Vessel]] wall thickening
**Luminal narrowing of pulmonary artery
**Luminal narrowing of [[pulmonary artery]]
**Masses or nodules (ANCA-associated granulomatous vasculitis)
**Masses or nodules ([[Anti-neutrophil cytoplasmic antibody|ANCA]]-associated granulomatous vasculitis)
*On MRI:
*On [[Magnetic resonance imaging|MRI]]:
Homogeneous, circumferential vessel wall swelling  
Homogeneous, circumferential [[Blood vessel|vessel]] wall [[swelling]]
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*Right or left bundle-branch block (Churg-Strauss syndrome)
*[[Bundle branch block|Right or left bundle-branch block]] ([[Churg-Strauss syndrome]])
*Atrial fibrillation (Churg-Strauss syndrome)
*[[Atrial fibrillation]] ([[Churg-Strauss syndrome]])
*Non-specific ST segment and T wave changes  
*Non-specific [[ST interval|ST segment]] and [[T wave]] changes  
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*Nodules
*[[Nodule (medicine)|Nodules]]
*Cavitation
*[[Cavitation]]
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*Takayasu arteritis usually found in persons aged 4-60 years with a mean of 30
*[[Takayasu's arteritis|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
*[[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
*[[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
*Granulomatous vasculitides may present with [[nephritis]] and [[upper airway]] ([[nasopharyngeal]]) destruction
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic obstructive pulmonary disease]] (COPD)
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic obstructive pulmonary disease]] (COPD)
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*On CT scan:
*On [[Computed tomography|CT scan]]:
**Chronic bronchitis may show bronchial wall thickening, scarring with bronchovascular irregularity, fibrosis
**[[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)
**[[Emphysema]] may show [[alveolar]] septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe)
**Giant bubbles
**Giant bubbles
*ON MRI:
*ON [[MRI]]:
**Increased diameter of pulmonary arteries
**Increased diameter of [[pulmonary arteries]]
**Peripheral pulmonary vasculature attentuation
**Peripheral [[pulmonary]] [[vasculature]] attentuation
**Loss of retrosternal airspace due to right ventricular enlargement
**Loss of retrosternal airspace due to right ventricular enlargement
**Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung
**Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung
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*Multifocal atrial tachycardia (atleast 3 distinct P wave morphologies)
*[[Multifocal atrial tachycardia]] (atleast 3 distinct [[P waves|P wave]] morphologies)
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*Enlarged lung shadows (emphysema)
*Enlarged [[lung]] shadows ([[emphysema]])
*Flattening of diaphragm (emphysema)
*Flattening of [[diaphragm]] ([[emphysema]])
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*Smoking
*[[Smoking]]
*Alpha-1 antitrypsin deficiency
*[[Alpha 1-antitrypsin deficiency|Alpha-1 antitrypsin deficiency]]
*Increased sputum production (chronic bronhitis)
*Increased [[sputum]] production ([[chronic bronchitis]])
*Cough
*[[Cough]]
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*Alpha 1 antitrypsin deficiency may be associated with hepatomegaly
*[[Alpha 1-antitrypsin deficiency|Alpha 1 antitrypsin deficiency]] may be associated with [[hepatomegaly]]
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Revision as of 21:04, 13 October 2017

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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

Homogeneous, circumferential vessel wall swelling

✔ ✔ ✔ ✔ ✔ ✔ - ✔ ✔ ✔
Chronic obstructive pulmonary disease (COPD)
  • On CT scan:
  • 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
 ✔ ✔ - - - ✔ ✔ - - -

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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