Bronchiolitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2]

Overview

Bronchiolitis must be differentiated from other respiratory and cardiac diseases that are presented with similar clinical manifestations. Based on cough and dyspnea, bronchiolitis is differentiated from asthma, COPD, pneumonia, congestive heart failure, diffuse idiopathic neuroendocrine cell hyperplasia, tuberculosis, pertussi, foreign body aspiration, pulmonary embolism and Harmann-Rich syndrome.

Differential Diagnosis

Bronchiolitis must be differentiated from other respiratory and cardiac diseases that can cause the same clinical manifestations like cough and dysnea.[1][2][3][4][5]

Differentiating bronchiolitis based on cough and dysnea

Based on cough and dyspnea, bronchiolitis is differentiated from asthma, COPD, pneumonia, congestive heart failure, diffuse idiopathic neuroendocrine cell hyperplasia, tuberculosis, pertussi, foreign body aspiration, pulmonary embolism and Harmann-Rich syndrome.

Diseases Symptoms Signs Diagosis
Fever Cough Chest pain Wheezes Crackles Edema Tachycardia Lab tests Imaging
Bronchiolitis +/- Dry - + + - +/-
  • Viral tests like ELISA and immunoassays may be done in case of RSV infection.
  • Pulmonary function test is performed to exclude other lung diseases.[6]
  • In CT scan, intense bronchiolar mural inflammation of cellular bronchiolitis results in centrilobular nodules that are usually associated with the tree-in-bud pattern and bronchial wall thickening
Asthma - Dry/Productive - + - + Pulmonary edema -
  • Lab tests are performed to exclude other diseases.
  • Serum examination shows elevated level of esoinophils due to allergy.
  • CT scan shows dilated bronchi, bronchial wall thickening and air trapping.
COPD + Productive - + + + +
  • Spirometry: FEV1/FVC < 70%
  • Atrial blood gases: hypoxemia and hypercapnia
  • Sputum culture
  • EKG may show P pulmonale, right ventricular hypertrophy and low QRS.[7]
  • CT scan is more sensitive in diagnosing COPD than X ray.
Bacterial pneumonia + Productive + + + - +/-
  • Diagnosis depends mainly on the presentation and physical examination.
  • Laboratory tests: arterial blood gases may show hypoxia and acidosis.
  • Sputum culture.
  • X ray is performed to detect pleural effusion and inflitrates within the lungs.
  • CT scan shows consolidation and ground glass appearance.
Pulmonary embolism +/- Bloody + + + + +
  • D-dimer level test is performed to rule out other diseases like DVT.
  • Routine blood tests are non specific.
  • Hypercoagulability tests are performed in patients with unprovoked venous thrombosis at an early age (< 40 years) and family history of VTE syndromes.
  • Arterial blood gases show the following:[8]
    • Hypoxemia
    • Hypocapnia
    • Respiratory alkalosis
    • Increased alveolar-arterial gradient
  • CT pulmonary angiography is the gold standard imaging to diagnose the pulmonary embolism. It shows the following:
    • Acute:Centrally located thrombus or occluding the vessel.
    • Chronic:Eccentric changes in the vessel wall, recanalization in the thrombous and arterial web.
  • EKG is not specific or sensitive in PE diagnosis but it may show T wave inversion, P pulmonale and sinus tachycardia.
  • Chest X ray is performed to exclude other differentials.
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia[9] - Dry - + - - -
  • Pulmonary function test shows obstructive lung disease
  • CT scan shows multiple nodules , ground glass appearance and bronchiectasis.
Tuberculosis + Bloody + - - + -
  • Sputum culture: three successive positive culture for M. tuberculosis confirms the diagnosis.[10]
  • The presence of acid fast bacilli in sputum smear indicates to high extent tuberculosis.
  • Chest X ray is an important diagnostic imaging procedure in TB diagnosis. It shows the following:[11]
    • Parenchymal infilration
    • Hilar adnopathy
    • Nodules
    • pleural effusion
  • CT scan shows the following:[12]
    • Micronodules
    • Cavitation
    • Consolidation
    • Interlobular septal thickening
  • EKG may have abnormalities in case pleural effussion associated with TB.
Interstitial pneumonitis (Hamman - Rich syndrome) + Productive - - + - -
  • Arterial blood gases: hypoxemia and PaO2/FiO2 less than 200 mmHg which indicates acute respiratory distress syndrome.
  • Other lab tests are usually used to exclude other diseases.
  • Chest X ray shows bilateral airway opacification.
  • CT scan shows ground glass appearance.
  • Bronchoscopy may be performed to exclude other causes like alveolar hemorrhage and lymphoma.
  • Lung biopsy is a last step in diagnosis of acute interstitial pnemonitis in order to confirm the disease and exclude other causes of ARDS.
Foreign body aspiration + Bloody + + - - -
  • Lab tests are performed to evaluate the ventilation function.
  • Chest X ray shows hyperinflation, mediastinal shift and atelectasis.
Pertussis + Dry - - - -
  • Nasopharyngeal swab for PCR testing.
  • Sputum culture
  • Serology to detect pertussis toxin.[13][14]
  • No remarkable imaging findings.
Congestive heart failure - Dry/Productive + while walking - - + +
  • Routine lab tests in order to know the cause of the heart failure:
    • Renal function tests including urinalysis and electrolytes assessment
    • Complete blood count
    • Thyroid studies specially in patients who are being treated with concomitant therapy with an agent such as amiodarone.
  • Biomarkers:
    • Natriuretic Peptides: BNP or NT-proBNP[15]
    • Biomarkers of myocardial Injury: Cardiac Troponin T or I
    • Carbohydrate Antigen 125[16]
  • EKG can be performed to detect the underlaying cause.
  • Chest x ray shows cardiomegaly.
  • Echocardiography is used to determine the stroke volume and to assess the heart failure.[17]

References

  1. ↑ Liu WY, Yu Q, Yue HM, Zhang JB, Li L, Wang XY; et al. (2016). "[The distribution characteristics of etiology of chronic cough in Lanzhou]". Zhonghua Jie He He Hu Xi Za Zhi. 39 (5): 362–7. doi:10.3760/cma.j.issn.1001-0939.2016.05.006. PMID 27180590.
  2. ↑ Environmental Triggers of Asthma. Differential Diagnosis of Asthma. Environmental Health and Medicine Education. Agency for Toxic Substances and Disease Registry. Available at: http://www.atsdr.cdc.gov/csem/csem.asp?csem=32&po=5. Accessed on February 25, 2016
  3. ↑ Mosley JD, Shaffer CM, Van Driest SL, Weeke PE, Wells QS, Karnes JH; et al. (2016). "A genome-wide association study identifies variants in KCNIP4 associated with ACE inhibitor-induced cough". Pharmacogenomics J. 16 (3): 231–7. doi:10.1038/tpj.2015.51. PMC 4713364. PMID 26169577.
  4. ↑ Jiang S, Li J, Zeng Q, Liang J (2017). "Pulmonary artery intimal sarcoma misdiagnosed as pulmonary embolism: A case report". Oncol Lett. 13 (4): 2713–2716. doi:10.3892/ol.2017.5775. PMC 5403205. PMID 28454456.
  5. ↑ Lin L, Chen Z, Cao Y, Sun G (2017). "Normal saline solution nasal-pharyngeal irrigation improves chronic cough associated with allergic rhinitis". Am J Rhinol Allergy. 31 (2): 96–104. doi:10.2500/ajra.2017.31.4418. PMID 28452705.
  6. ↑ Ghanei M, Tazelaar HD, Chilosi M, Harandi AA, Peyman M, Akbari HM; et al. (2008). "An international collaborative pathologic study of surgical lung biopsies from mustard gas-exposed patients". Respir Med. 102 (6): 825–30. doi:10.1016/j.rmed.2008.01.016. PMID 18339530.
  7. ↑ Lazović B, Svenda MZ, Mazić S, Stajić Z, Delić M (2013). "Analysis of electrocardiogram in chronic obstructive pulmonary disease patients". Med Pregl. 66 (3–4): 126–9. PMID 23653989.
  8. ↑ Cvitanic O, Marino PL (1989). "Improved use of arterial blood gas analysis in suspected pulmonary embolism". Chest. 95 (1): 48–51. PMID 2491801. Retrieved 2012-04-30. Unknown parameter |month= ignored (help)
  9. ↑ Nassar AA, Jaroszewski DE, Helmers RA, Colby TV, Patel BM, Mookadam F (2011). "Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: a systematic overview". Am J Respir Crit Care Med. 184 (1): 8–16. doi:10.1164/rccm.201010-1685PP. PMID 21471097.
  10. ↑ Drobniewski F, Caws M, Gibson A, Young D (2003). "Modern laboratory diagnosis of tuberculosis". Lancet Infect Dis. 3 (3): 141–7. PMID 12614730.
  11. ↑ Riccardo Piccazzo, Francesco Paparo & Giacomo Garlaschi (2014). "Diagnostic accuracy of chest radiography for the diagnosis of tuberculosis (TB) and its role in the detection of latent TB infection: a systematic review". The Journal of rheumatology. Supplement. 91: 32–40. doi:10.3899/jrheum.140100. PMID 24788998. Unknown parameter |month= ignored (help)
  12. ↑ Jeong Min Ko, Hyun Jin Park & Chi Hong Kim (2014). "Pulmonary Changes of Pleural Tuberculosis: Up-to-Date CT Imaging". Chest. doi:10.1378/chest.14-0196. PMID 25086249. Unknown parameter |month= ignored (help)
  13. ↑ Pertussis (whooping coug). Diagnosis confirmation. CDC.gov. Accessed on June 22, 2017
  14. ↑ Pertussis (whooping cough). Specimen collection. CDC.gov. Accessed on June 22, 2017
  15. ↑ Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL (2013). "2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J. Am. Coll. Cardiol. 62 (16): e147–239. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  16. ↑ D'Aloia A, Vizzardi E, Metra M (2016). "Can Carbohydrate Antigen-125 Be a New Biomarker to Guide Heart Failure Treatment?: The CHANCE-HF Trial". JACC Heart Fail. 4 (11): 844–846. doi:10.1016/j.jchf.2016.09.001. PMID 27810078.
  17. ↑ Agha SA, Kalogeropoulos AP, Shih J, Georgiopoulou VV, Giamouzis G, Anarado P, Mangalat D, Hussain I, Book W, Laskar S, Smith AL, Martin R, Butler J (2009). "Echocardiography and risk prediction in advanced heart failure: incremental value over clinical markers". J. Card. Fail. 15 (7): 586–92. doi:10.1016/j.cardfail.2009.03.002. PMID 19700135.

References


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