Cough, fever, and weight loss

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Karina Zavaleta, MD [2],  Anmol Pitliya, M.B.B.S. M.D.[3]

## Cough, fever, and Weight loss differential diagnosis

[edit | edit source]

Organ system  | Diseases  | Clinical manifestations  | Diagnosis  | Other features

|
|
|
|

Symptoms  | Physical exam
Onset  | Duration  | Productive cough  | Hemoptysis  | Weight lost  | Fever  | Dyspnea  | Ascultation  | Lab findings  | Imaging  | PFT  | Gold standard
Respiratory | Upper airway diseases | Pertussis[1][2] | Acute  |

* Two weeks

| \+ Whooping sound  | −  | \+  | \+  | \+  |

* Clear chest

* Polymerase chain reaction (PCR) shows Bordetella pertussis
* Serologic testing

* Atelectasis may seen on chest imaging
* Lymphadenopathy

* Normal function

* Culture

* Etiology: Bordetella pertussis
* Phases: Catarrhal, paroxysmal and convalescent

Respiratory | Parenchyma | Pneumoconioses[3][4] | Acute, Chronic  |

* Years

| −  | −  | \+  | \+  | \+  |

* Wheezing
* Rhonchi
* Crackles

* CBC and ABG may be helpful

* Small oppacities and fibrosis observed in chest X−ray
* CT and FDG−PET may be helpful

* FEV1/FVC <70%
* FEV1 <80%

* Exposure history and chest radiograph

* Fibrogenic: Silica, asbestos
* Inert: Iron, barium
* Granulomatous: Beryllium
* Giant cell pneumonia: Cobalt

Lung cancer[5][6] | Chronic  |

* Years

| \+  | \+  | \+  | +/−  | \+  |

* Hoarseness

| The following investigations may be helpful:

* Complete blood count (CBC)
* ALT, AST
* Calcium
* Alkaline phosphatase
* LDH
* Creatinine

* Contrast−enhanced CT of chest and upper abdomen

* Not specific

* Tissue biopsy (sample should be sufficient for molecular testing)

* Risk factor:
* Cigarette smoking
* Types
* Small cell lung cancer (SCLC)
* Non−small cell lung cancer (NSCLC)

Tuberculosis (TB)[7][8] | Chronic  |

* More than 2 or 3 weeks

| \+  | \+  | \+  | \+  | \+  |

* Pleural effusion
* Crackles
* Whispered pectoriloquy
* Decreased fremitus
* Rhonchi

* Sputum acid−fast bacilli (AFB) smear may be positive
* Mycobacterial culture may be positive
* Molecular testing may be helpful

* Reactivation of TB is observed as infiltration in the upper lobe in chest X−Ray
* In patients with HIV, Tb is observed as lobar infiltration, adenopathy, lung mass named tuberculoma, small fibronodular lesions, and/or pleural effusion on chest X−Ray
* CT can detect early nodal process

* Decreased FEV1
* Reduced FVC

* Isolation of Mycobacterium tuberculosis from some secretion

* Etiology: Mycobacterium tuberculosis
* Complications: Pneumothorax, bronchiectasis, pulmonary destruction and chronic pulmonary aspergillosis

Cystic fibrosis (CF)[9][10] | Chronic  |

* Variable

| \+  | −  | \+  | +/−  | \+  |

* Barrel−shaped chest
* Wheezing
* Tachypnea

* Respiratory tract culture may be helpful for diagnosing secondary bacterial infection
* Bronchoalveolar lavage for cytology may be helpful
* ≥ 60 mmol/L Sweat chloride test
* CFTR mutation in molecular testing may be positive

* Hyperinflation, atelectasis, and infiltrates on chest X−Ray
* Severe patients present bronchietasis, "tram tracks" peribronchial cuffing in chest X−Ray
* The extension of bronchietasis can be defined by CT

* RV/TLC ratio increased
* FEV1/FVC ratio <70%
* Low levels of FEV1
* High levels of TLC
* RV increased

* Sweat chloride test

* Evidence of CFTR dysfunction

Organ system  | Diseases  | Clinical manifestations  | Diagnosis  | Other features
Symptoms  | Physical exam
Onset  | Duration  | Productive cough  | Hemoptysis  | Weight lost  | Fever  | Dyspnea  | Ascultation  | Lab findings  | Imaging  | PFT  | Gold standard
Autoimmune | Wegener's disease (GPA) [11][12] | Chronic  |

* Months

| \+  | \+  | \+  | \+  | \+  |

* Hoarseness
* Stridor
* Wheezing

| The following investigations may be helpful:

* ANCA, P−ANCA, C−ANCA
* BUN
* Creatinine
* Complete blood count
* Urinalysis
* Lung biopsy

* Nodules, pulmonary infiltrates, reticular margins, pleural opacities and cavities in chest X−Ray
* Nodules, cavities and stellate−shaped peripherial pulmonary in chest CT
* Bronchoscopy may be helpful

* Low levels of DLCO
* Reduce lung volumes

* Tissue biopsy

* Nasal crusting, sinus pain, chronic rhinosinusitis, nasal obstruction and discharge in upper airway
* Saddle nose deformity
* Purpura in lower extremities

Sarcoidosis[13][14] | Chronic  |

* Years

| −  | −  | \+  | \+  | \+  |

* Wheezing
* Squeaky sounds

| The following investigations may be helpful:

* Complete blood count (CBC)
* Urinalysis
* BUN
* Liver function test
* Calcium
* Alkaline phosphatase levels
* Electrolytes
* Histopathologic detection

* On chest X−Ray:
* Stage 1: Bilateral hiliar adenopathy
* Stage 2: Reticular opacities and hiliar adenopathy
* Stage 3: Shrink hiliar nodules and reticular opacities
* Stage 4: Lost of volume

* Reduced FVC
* Decreased of TLC

* Clinical diagnosis, histopathologic detection of noncaseating granulomas and exclusion of other diseases

* Young adults
* Skin, joint and eye lesions

Microscopic polyangitis (MPA)[15] | Chronic  |

* Variable

| \+  | \+  | \+  | \+  | \+  |

* Hoarseness
* Stridor
* Wheezing

| The following investigations may be helpful:

* ANCA positive
* BUN
* Creatinine
* Complete blood count
* Urinalysis

* Cavitation, nodules, and alveolar opacities in chest X−ray
* Head and chest CT may be helpful
* Electromyography/nerve conduction study may also be helpful

* Reduced lung volumes

* Tissue biopsy

* Nerve damage
* Rhinosinusitis
* Purpura involving lower extremities

Churg−Strauss[16][17] | Chronic  |

* Variable

| \+  | \+  | \+  | \+  | \+  |

* Wheezing
* Rales
* Rhonchi
* Expiratory sounds(related to asthma)

* Peripherial eosinophilia
* In active phase CRP and erytrocyte sedimentation rate high
* Elevated IgE
* ANCA positive

* Infiltrates in chest X−Ray
* Ground glass opacities, tree−in−bud sign and small nodules in chest CT

* Lung volumes decreased
* FVC reduced
* FEV1/FVC ratio <70%

* Tissue biopsy

* Asthma
* Eosinophilia
* Rhinosinusitis

## References

[edit | edit source]

1. ↑ Bellamy EA, Johnston ID, Wilson AG (1987). "The chest radiograph in whooping cough". Clin Radiol. 38 (1): 39–43. PMID 3816065.
2. ↑ "Pertussis | Whooping Cough | Clinical | Information | CDC".
3. ↑ Jp NA, Imanaka M, Suganuma N (2017). "Japanese workplace health management in pneumoconiosis prevention". J Occup Health. 59 (2): 91–103. doi:10.1539/joh.16-0031-RA. PMC 5478517. PMID 27980247.
4. ↑ Weiland DA, Lynch DA, Jensen SP, Newell JD, Miller DE, Crausman RS, Kuhn C, Kern DG (2003). "Thin-section CT findings in flock worker's lung, a work-related interstitial lung disease". Radiology. 227 (1): 222–31. doi:10.1148/radiol.2271011063. PMID 12668748.
5. ↑ Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D (2011). "Global cancer statistics". CA Cancer J Clin. 61 (2): 69–90. doi:10.3322/caac.20107. PMID 21296855.
6. ↑ Ost DE, Jim Yeung SC, Tanoue LT, Gould MK (2013). "Clinical and organizational factors in the initial evaluation of patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines". Chest. 143 (5 Suppl): e121S–e141S. doi:10.1378/chest.12-2352. PMC 4694609. PMID 23649435.
7. ↑ Perlman DC, el-Sadr WM, Nelson ET, Matts JP, Telzak EE, Salomon N, Chirgwin K, Hafner R (1997). "Variation of chest radiographic patterns in pulmonary tuberculosis by degree of human immunodeficiency virus-related immunosuppression. The Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA). The AIDS Clinical Trials Group (ACTG)". Clin. Infect. Dis. 25 (2): 242–6. PMID 9332519.
8. ↑ Barnes PF, Verdegem TD, Vachon LA, Leedom JM, Overturf GD (1988). "Chest roentgenogram in pulmonary tuberculosis. New data on an old test". Chest. 94 (2): 316–20. PMID 2456183.
9. ↑ Farrell PM, Rosenstein BJ, White TB, Accurso FJ, Castellani C, Cutting GR, Durie PR, Legrys VA, Massie J, Parad RB, Rock MJ, Campbell PW (2008). "Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report". J. Pediatr. 153 (2): S4–S14. doi:10.1016/j.jpeds.2008.05.005. PMC 2810958. PMID 18639722.
10. ↑ Kerem E, Reisman J, Corey M, Canny GJ, Levison H (1992). "Prediction of mortality in patients with cystic fibrosis". N. Engl. J. Med. 326 (18): 1187–91. doi:10.1056/NEJM199204303261804. PMID 1285737.
11. ↑ Hoffman GS, Kerr GS, Leavitt RY, Hallahan CW, Lebovics RS, Travis WD, Rottem M, Fauci AS (1992). "Wegener granulomatosis: an analysis of 158 patients". Ann. Intern. Med. 116 (6): 488–98. PMID 1739240.
12. ↑ Falk RJ, Gross WL, Guillevin L, Hoffman GS, Jayne DR, Jennette JC, Kallenberg CG, Luqmani R, Mahr AD, Matteson EL, Merkel PA, Specks U, Watts RA (2011). "Granulomatosis with polyangiitis (Wegener's): an alternative name for Wegener's granulomatosis". Arthritis Rheum. 63 (4): 863–4. doi:10.1002/art.30286. PMID 21374588.
13. ↑ Carmona EM, Kalra S, Ryu JH (2016). "Pulmonary Sarcoidosis: Diagnosis and Treatment". Mayo Clin. Proc. 91 (7): 946–54. doi:10.1016/j.mayocp.2016.03.004. PMID 27378039.
14. ↑ Yanardağ H, Pamuk GE, Karayel T, Demirci S (2002). "Bone marrow involvement in sarcoidosis: an analysis of 50 bone marrow samples". Haematologia (Budap). 32 (4): 419–25. PMID 12803116.
15. ↑ Jennette, J. Charles; Falk, Ronald J. (1997). "Small-Vessel Vasculitis". New England Journal of Medicine. 337 (21): 1512–1523. doi:10.1056/NEJM199711203372106. ISSN 0028-4793.
16. ↑ Vaglio A, Buzio C, Zwerina J (2013). "Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): state of the art". Allergy. 68 (3): 261–73. doi:10.1111/all.12088. PMID 23330816.
17. ↑ Lanham JG, Elkon KB, Pusey CD, Hughes GR (1984). "Systemic vasculitis with asthma and eosinophilia: a clinical approach to the Churg-Strauss syndrome". Medicine (Baltimore). 63 (2): 65–81. PMID 6366453.