Emphysema differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: : Mehrian Jafarizade, M.D [2]

## Overview[edit | edit source]

Emphysema must be differentiated from other diseases presenting with cough, shortness of breath and tachypnea, such as congestive heart failure, asthma, bronchiectasis, and bronchiolitis obliterans, pulmonary embolism, pericarditis, and vasculitis.

## Differential Diagnosis[edit | edit source]

Emphysema should be differentiated from other diseases presenting with chronic cough, shortness of breath and tachypnea. The differentials include the following:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]

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)

* S1Q3T3 pattern representing acute right heart strain

* Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign

| ✔  | ✔  | ✔ (Low grade)  | ✔  | ✔ (In case of massive PE)  | ✔  | \-  | \-  | \-  | \-  |

* Hypercoagulating conditions (Factor V Leiden, thrombophilia, deep vein thrombosis, immobilization, malignancy, pregnancy)

* May be associated with metabolic alkalosis and syncope

Congestive heart failure |

* On CT scan:
* Mediastinal lymphadenopathy
* Hazy mediastinal fat
* On MRI:
* Abnormality of cardiac chambers (hypertrophy, dilation)
* Delayed enhancement MRI may help characterize the myocardial tissue (fibrosis)
* Late enhancement of contrast in conditions such as myocarditis, sarcoidosis, amyloidosis, Anderson-Fabry's disease, Chagas disease)

* 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

* Cardiomegaly

| ✔  | ✔  | ✔  | \-  | \-  | ✔  | \-  | \-  | \-  | \-  |

* Previous myocardial infarction
* Hypertension (systemic and pulmonary)
* Cardiac arrythmias
* Viral infections (myocarditis)
* Congenital heart defects

* Right heart failure associated with:
* Hepatomegaly
* Positive hepato-jugular reflex
* Increased jugular venous pressure
* Peripheral edema
* Left heart failure associated with:
* Pulmonary edema
* Eventual right heart failure

Percarditis |

* On contrast enhanced CT scan:
* Enhancement of the pericardium (due to inflammation)
* Pericardial effusion
* Pericardial calcification
* On gadolinium-enhanced fat-saturated T1-weighted MRI:
* Pericardial enhancement (due to inflammation)
* Pericardial effusion

* 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)  | \-  | ✔  | \-  | \-  | \-  | \-  |

* Infections:
* Viral (Coxsackie virus, Herpes virus, Mumps virus, HIV)
* Bacteria (Mycobacterium tuberculosis-common in developing countries)
* Fungal (Histoplasmosis)
* Idiopathic in a large number of cases
* Autoimmune
* Uremia
* Malignancy
* Previous myocardial infarction

* May be clinically classified into:
* Acute (< 6 weeks)
* Sub-acute (6 weeks - 6 months)
* Chronic (> 6 months)

Pneumonia |

* On CT scan: (not generally indicated)
* Consolidation (alveolar/lobar pneumonia)
* Peribronchial nodules (bronchopneumonia)
* Ground-glass opacity (GGO)
* Abscess
* Pleural effusion
* On MRI:
* Not indicated

* Prolonged PR interval
* Transient T wave inversions

* Consolidation (alveolar/lobar pneumonia)
* Peribronchial nodules (bronchopneumonia)
* Ground-glass opacity (GGO)

| ✔  | ✔  | ✔  | ✔  | \-  | ✔  | ✔  | \-  | \-  | \-  |

* Ill-contact
* Travelling
* Smoking
* Diabetic
* Recent hospitalization
* Chronic obstructive pulmonary disease

* Requires sputum stain and culture for diagnosis
* Empiric management usually started before culture results

Vasculitis |

* On CT scan: (Takayasu arteritis)
* Vessel wall thickening
* Luminal narrowing of pulmonary artery
* Masses or nodules (ANCA-associated granulomatous vasculitis)
* On MRI:

Homogeneous, circumferential vessel wall swelling

* Right or left bundle-branch block (Churg-Strauss syndrome)
* Atrial fibrillation (Churg-Strauss syndrome)
* Non-specific ST segment and T wave changes

* Nodules
* Cavitation

| ✔  | ✔  | ✔  | ✔  | ✔  | ✔  | \-  | ✔  | ✔  | ✔  |

* 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
* Churg-Strauss syndrome may present with asthma, sinusitis, transient pulmonary infiltrates and neuropathy alongwith cardiac involvement
* Granulomatous vasculitides may present with nephritis and upper airway (nasopharyngeal) destruction

Chronic obstructive pulmonary disease (COPD)  |

* On CT scan:
* 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)
* Giant bubbles
* 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

* Multifocal atrial tachycardia (atleast 3 distinct P wave morphologies)

* Enlarged lung shadows (emphysema)
* Flattening of diaphragm (emphysema)

| ✔  | ✔  | \-  | \-  | \-  | ✔  | ✔  | \-  | \-  | \-  |

* Smoking
* Alpha-1 antitrypsin deficiency
* Increased sputum production (chronic bronchitis)
* Cough

* Alpha 1 antitrypsin deficiency may be associated with hepatomegaly

### Features Specific for Congestive Heart Failure[edit | edit source]

Chronic obstructive pulmonary disease (COPD) may be confused with congestive heart failure due to similar presentations like wheezing and shortness of breath. Features specific to congestive heart failure are:

* Orthopnea
* Paroxysmal nocturnal dyspnea
* Fine crackles on ausculatation
* Chest X ray findings of cardiac enlargement, pulmonary congestion (Kerley B lines, and pleural effusion)
* The peak expiratory flow is low in COPD whereas there is higher flow in heart failure
* Comet-tail sign on ultrasonography is a good indicator of heart failure–related dyspnea

### Features Specific for Bronchiectasis[edit | edit source]

* Copious purulent sputum
* Coarse crackles
* Clubbing
* CT findings suggestive of Bronchiectasis.

### Features Specific for Bronchiolitis Obliterans[edit | edit source]

* History of collagen vascular disease.
* Young patient usually without a history of smoking
* CT scan shows finding of mosaic attenuation and no evidence of emphysema.

### Features Specific for Chronic Asthma[edit | edit source]

* Chronic asthma responds well to bronchodilators.
* Normal diffusion capacity of lung on pulmonary function test.

## References[edit | edit source]

1. ↑ Brenes-Salazar JA (2014). "Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era". J Emerg Trauma Shock. 7 (1): 57–8. doi:10.4103/0974-2700.125645. PMC 3912657. PMID 24550636.
2. ↑ "CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics".
3. ↑ Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.
4. ↑ "Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health".
5. ↑ Ramani GV, Uber PA, Mehra MR (2010). "Chronic heart failure: contemporary diagnosis and management". Mayo Clin. Proc. 85 (2): 180–95. doi:10.4065/mcp.2009.0494. PMC 2813829. PMID 20118395.
6. ↑ Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL (2008). "Symptom distress and quality of life in patients with advanced congestive heart failure". J Pain Symptom Manage. 35 (6): 594–603. doi:10.1016/j.jpainsymman.2007.06.007. PMC 2662445. PMID 18215495.
7. ↑ Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ (2009). "Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology". Eur. J. Heart Fail. 11 (2): 130–9. doi:10.1093/eurjhf/hfn013. PMC 2639415. PMID 19168510.
8. ↑ Takasugi JE, Godwin JD (1998). "Radiology of chronic obstructive pulmonary disease". Radiol. Clin. North Am. 36 (1): 29–55. PMID 9465867.
9. ↑ Wedzicha JA, Donaldson GC (2003). "Exacerbations of chronic obstructive pulmonary disease". Respir Care. 48 (12): 1204–13, discussion 1213–5. PMID 14651761.
10. ↑ Nakawah MO, Hawkins C, Barbandi F (2013). "Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome". J Am Board Fam Med. 26 (4): 470–7. doi:10.3122/jabfm.2013.04.120256. PMID 23833163.
11. ↑ Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (2010). "Pericardial disease: diagnosis and management". Mayo Clin. Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
12. ↑ Bogaert J, Francone M (2013). "Pericardial disease: value of CT and MR imaging". Radiology. 267 (2): 340–56. doi:10.1148/radiol.13121059. PMID 23610095.
13. ↑ Gharib AM, Stern EJ (2001). "Radiology of pneumonia". Med. Clin. North Am. 85 (6): 1461–91, x. PMID 11680112.
14. ↑ Schmidt WA (2013). "Imaging in vasculitis". Best Pract Res Clin Rheumatol. 27 (1): 107–18. doi:10.1016/j.berh.2013.01.001. PMID 23507061.
15. ↑ Suresh E (2006). "Diagnostic approach to patients with suspected vasculitis". Postgrad Med J. 82 (970): 483–8. doi:10.1136/pgmj.2005.042648. PMC 2585712. PMID 16891436.
16. ↑ Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). "The electrocardiogram in acute pulmonary embolism". Prog Cardiovasc Dis. 17 (4): 247–57. PMID 123074.
17. ↑ Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML (2013). "Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease". COPD. 10 (1): 62–71. doi:10.3109/15412555.2012.727918. PMID 23413894.
18. ↑ Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H (2012). "Electrocardiogram in pneumonia". Am. J. Cardiol. 110 (12): 1836–40. doi:10.1016/j.amjcard.2012.08.019. PMID 23000104.
19. ↑ Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S (2015). "Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis". Int. J. Cardiol. 199: 170–9. doi:10.1016/j.ijcard.2015.06.087. PMID 26209947.
20. ↑ Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S (2010). "Cardiac involvement in Churg-Strauss syndrome". Arthritis Rheum. 62 (2): 627–34. doi:10.1002/art.27263. PMID 20112390.