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 present with similar clinical manifestations of cough and dyspnea. Bronchiolitis should be differentiated from asthma, COPD, pneumonia, congestive heart failure, diffuse idiopathic neuroendocrine cell hyperplasia, tuberculosis, pertussis, foreign body aspiration, pulmonary embolism, and Harman-Rich syndrome.

Differentiating bronchiolitis from other diseases

Bronchiolitis must be differentiated from other respiratory and cardiac diseases that can cause the similar clinical manifestations like cough and dyspnea. The differentials include the follwoing:^[1]^[2]^[3]^[4]^[5]

Diseases	Symptoms			Signs			Diagosis
Diseases	Fever	Chest pain	Cough	Wheeze	Crackles	Tachycardia	Lab tests	Imaging
Bronchiolitis	+/-	-	Dry	+	+	+/-	ELISA and immunoassays may be done in case of RSV infection Pulmonary function test to exclude other lung diseases^[6]	CT scan shows: Intense bronchiolar mural inflammation Bronchial wall thickening Centrilobular nodules with tree-in-bud pattern
Asthma	-	-	Dry/Productive	+	-	-	Pulmonary function tests (PFT) to exclude other diseases Serum examination shows elevated level of eosinophils due to allergy	CT scan shows: Dilated bronchi Bronchial wall thickening Air trapping
Chronic obstructive pulmonary disease (COPD)	+	-	Productive	+	+	+	Spirometry: FEV1/FVC < 70% Arterial blood gases: Hypoxemia Hypercapnia Sputum culture	EKG may show: P pulmonale Right ventricular hypertrophy Narrow QRS^[7] CT scan is more sensitive in diagnosing COPD than X-ray
Bacterial pneumonia	+	+	Productive	+	+	+/-	Diagnosis depends on presentation and physical examination Laboratory tests Arterial blood gases may show hypoxia and acidosis Sputum culture	Chest X-ray may show: Pleural effusion Inflitrates within the lungs CT scan may show: Consolidation Ground glass appearance
Pulmonary embolism (PE)	+/-	+	Bloody	+	+	+	Arterial blood gases may show:^[8] Hypoxemia Hypocapnia Respiratory alkalosis Increased alveolar-arterial gradient D-dimer assay may show elevated levels of D-dimers Hypercoagulability tests for patients with: Unprovoked venous thrombosis at an early age (< 40 years) Family history of VTE syndromes Routine blood tests are non specific	CT pulmonary angiography is the gold standard imaging to diagnose pulmonary embolism. CT may show: Acute: Centrally located thrombus occluding the vessel Chronic: Eccentric changes in the vessel wall, recanalization in the thrombous and arterial web EKG is neither specific nor sensitive in diagnosing PE but it may show: T wave inversion P pulmonale Sinus tachycardia Chest X-ray to exclude other differentials
Diffuse idiopathic neuroendocrine cell hyperplasia^[9]	-	-	Dry	+	-	-	Pulmonary function test shows obstructive lung disease (FEV1/FVC less than 0.7)	CT scan may show: Multiple nodules Ground glass appearance Bronchiectasis
Tuberculosis	+	+	Bloody	-	-	-	Sputum culture: Three successive positive cultures for M. tuberculosis confirm the diagnosis^[10] Presence of acid fast bacilli in sputum smear indicates tuberculosis	Chest X-ray is an important diagnostic imaging procedure in TB diagnosis. X-ray may show:^[11] Parenchymal infilration Hilar adenopathy Nodules Pleural effusion CT scan may show:^[12] Micronodules Cavitation Consolidation Interlobular septal thickening EKG may show abnormalities in the case of pleural effusion associated with TB. These abnormalities include: Low QRS voltage Electrical alternans
Interstitial pneumonitis (Hamman - Rich syndrome)	+	-	Productive	-	+	-	Arterial blood gases may show: Hypoxemia PaO2/FiO2 less than 200 mmHg indicating acute respiratory distress syndrome Other lab tests are done to exclude other diseases	Chest X-ray may show: Bilateral opacification CT scan may show Ground glass appearance Bronchoscopy to exclude other causes such as: Alveolar hemorrhage Lymphoma Lung biopsy is done: In unclear cases; to confirm acute interstitial pneumonitis Exclude other causes of ARDS
Foreign body aspiration	+	+	Bloody	+	-	-	Lab tests to evaluate the ventilation function	Chest X-ray shows: Hyperinflation Mediastinal shift Atelectasis
Pertussis	+		Dry	-	-	-	Nasopharyngeal swab for PCR testing Sputum culture Serology to detect pertussis toxin^[13]	No remarkable imaging findings
Congestive heart failure	-	+ while walking	Dry/Productive	-	-	+	Routine lab tests to identify the cause of the heart failure: Renal function tests including urinalysis and electrolytes Complete blood count Thyroid studies in patients being treated with concomitant therapy such as amiodarone Biomarkers: BNP or NT-proBNP^[14] Cardiac troponin T or I Carbohydrate Antigen 125^[15]	EKG to detect underlying cause Chest X-ray shows cardiomegaly Echocardiography is done: To determine stroke volume To assess type of heart failure^[16]

References

↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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
↑ 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.
↑ 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.
↑ 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)
↑ 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.
↑ Drobniewski F, Caws M, Gibson A, Young D (2003). "Modern laboratory diagnosis of tuberculosis". Lancet Infect Dis. 3 (3): 141–7. PMID 12614730.
↑ 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)
↑ 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)
↑ Pertussis (whooping coug). Diagnosis confirmation. CDC.gov. Accessed on June 22, 2017
↑ 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.
↑ 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.
↑ 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

Template:WikiDoc Sources

[pmid27180590-1] 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.

[pmid28452705-2] 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.

[pmid28454456-3] 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.

[pmid26169577-4] 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.

[cdc-5] 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

[pmid18339530-6] 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.

[pmid23653989-7] 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.

[pmid2491801-8] 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)

[pmid21471097-9] 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.

[pmid12614730-10] 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)

[CDC4-13] Pertussis (whooping coug). Diagnosis confirmation. CDC.gov. Accessed on June 22, 2017

[pmid23747642-14] 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.

[pmid27810078-15] 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.

[pmid19700135-16] 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.

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Bronchiolitis differential diagnosis

Overview

Differentiating bronchiolitis from other diseases

References

References

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