Caplans syndrome differential diagnosis

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

Overview

Caplan syndrome must be differentiated from asbestosis, silicosis, and tuberculosis.

Differentiating Caplan syndrome from other Diseases

Caplan syndrome must be differentiated from asbestosis, silicosis and other respiratory diseases with lung lesions.

Disease	Findings
Bacterial pneumonia	Sudden onset of symptoms, such as high fever, cough, purulent sputum, chest pain, leukocytosis, chest X-ray shows consolidation.
Bronchogenic carcinoma	may be asymptomatic, usually at older ages (> 50 years old), cough, hemoptysis, weight loss
Brucellosis	Fever, anorexia, night sweats, malaise,back pain , headache, and depression. History of exposure to infected animal
Hodgkin lymphoma	Fever, night sweats, pruritus, painless adenopathy, mediastinal mass
Mycoplasmal pneumonia	Gradual onset of dry cough, headache, malaise, sore throat. Diffuse bilateral infiltrates on chest X-ray.
Sarcoidosis	Non-caseating granulomas in lungs and other organs, bilateral hilar lymphadenopathy, mostly in African American females.
Caplan syndrome	Initially asymptomatic but advanced stages are associated with shortness of breath, cough and wheeze in the chest. Mostly in miners with preexisting rheumatoid arthritis.
Adapted from Mandell, Douglas, and Bennett's principles and practice of infectious diseases 2010

Causes of lung cavities	Differentiating Features	Differentiating radiological findings	Diagnosis confirmation
Malignancy (Primary lung cancer)	Elderly male or female Chronic smokers Presents with a low-grade fever, absence of leukocytosis, systemic complaints weight loss, fatigue Absence of factors that predispose to gastric content aspiration, no response to antibiotics within 10 days Hemoptysis is commonly associated with bronchogenic carcinoma	A coin-shaped lesion with a thick wall(>15mm) is seen on CXR with fewer ground-glass opacities Bronchoalveolar lavage cytology shows malignant cells	Biopsy of lung
Pulmonary Tuberculosis	Mostly in endemic areas Symptoms include productive cough,night sweats, fever and weight loss	CXR and CT demonstrates cavities in the upper lobe of the lung	Sputum smear-positive for acid-fast bacilli and nucleic acid amplification tests (NAAT) is used on sputum or any sterile fluid for rapid diagnosis and is positive for mycobacteria.
Necrotizing Pneumonia	Any age group Acute, fulminant life threating complication of prior infection >100.4F fever, with hemodynamic instability Worsening pneumonia-like symptoms	CXR demonstrates multiple cavitary lesions Pleural effusion and empyema are common findings	CBC is positive for the causative organism
Loculated empyema	Children and elderly are at risk Pleuritic chest pain, dry cough, fever with chills Dullness to percussion decreased breath sounds, and reduced vocal resonance on examination	Empyema appears lenticular in shape and has a thin wall with smooth luminal margins	Thoracocentesis
Granulomatosis with polyangiitis (Wegener's)	Women are more commonly effected than man. Kidneys are also involved Upper respiratory tract symptoms , perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis. Lower respiratory tract symptoms, hemoptysis, cough, dyspnea. Renal symptoms, hematuria, red cell casts	Pulmonary nodules with cavities and infiltrates are a frequent manifestation of CXR	Positive for P-ANCA Biopsy of the affected tissue shows necrotizing granulomas
Rheumatoid nodule	Elderly females of 40-50 age group Manifestation of rheumatoid arthritis Presents with other systemic symptoms including symmetric arthritis of the small joints of the hands and feet and morning stiffness are common manifestations.	Pulmonary nodules with cavitation are present in the upper lobe (Caplan syndrome) on Xray.	Positive for both rheumatoid factor and anti-cyclic citrullinated peptide antibody.
Sarcoidosis	More common in African-American females Often asymptomatic except for enlarged lymph nodes Associated with restrictive lung disease Erythema nodosum Lupus pernio (skin lesions on face resembling lupus) Bell palsy Epithelioid granulomas containing microscopic Schaumann and asteroid bodies	On CXR bilateral adenopathy and coarse reticular opacities are seen. CT of the chest demonstrates extensive hilar and mediastinal adenopathy Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities.	Biopsy of lung reveals non-caseating granuloma
Bronchiolitis obliterans (Cryptogenic organizing pneumonia)	Rare condition and mimics asthma, pneumonia and emphysema It is due to drug or toxin exposure, autoimmune diseases, viral infections, or radiation injury Individuals working in industries are at high risk Presents with fever, cough, wheezing and shortness of breath over weeks to months,	Common appearance on CT is patchy consolidation,often accompanied by ground-glass opacities and nodules.	Biopsy of the lung Pulmonary function tests demonstrate low fev1/fvc
Langerhans cell Histiocytosis	Exclusively occurs in smokers, with a peak age of onset 20-40 years. Clinical presentation is variable, but symptoms generally include months of dry cough, fever, night sweats and weight loss. Skin is involved in 80% of the cases, scaly erythematous rash is typical.	Thin-walled cystic cavities are the usual radiographic manifestation, observed in over 50% of patients by either CXR or CT scans.	Biopsy of the lung
Caplan syndrome	Mostly occurs in miners with rheumatoid arthritis. Usually asymptomatic in the initial stages. Dyspnea and cough can occur in advanced stages. Miners with Caplan nodule without rheumatoid arthritis can develop arthritis after 5-10 years later.	Well-defined, cavitating lung nodules of 0.5-5 cm is the usual finding in a chest x-ray and CT scan.	Biopsy of the lung nodules.