Pulmonary nodule differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Solitary pulmonary nodule}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Pulmonary_nodule]]
{{CMG}}{{AE}}{{MV}}
{{CMG}}; {{AE}} {{Trusha}}, {{JE}}, {{MV}}
==Overview==
==Overview==


Pulmonary nodule may be differentiated according to imaging (size, border characteristics, and attenuation), histological, and clinical features, from other diseases that demonstrate similar imaging findings. Common differential diagnosis of pulmonary nodule, include: [[hamartoma]], [[granulomas]], [[Nodule|rheumatoid nodule]], and [[Metastasis|single metastasis]].<ref name="NEJM-cp">{{cite journal |author=Ost D, Fein AM, Feinsilver SH |title=Clinical practice. The solitary pulmonary nodule |journal=N. Engl. J. Med. |volume=348 |issue=25 |pages=2535–42 |year=2003 |month=June |pmid=12815140 |doi=10.1056/NEJMcp012290 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12815140&promo=ONFLNS19}}</ref><ref name="NEJM">McWilliams A, Tammemagi MC, Mayo JR, et. al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013 Sep 5;369(10):910-9. doi:10.1056/NEJMoa1214726.</ref>
Pulmonary nodule may be differentiated according to [[imaging]] (size, border characteristics, and attenuation), [[Histology|histological]], and clinical features, from other diseases that demonstrate similar [[imaging]] findings. Common [[Differential diagnosis|differential diagnoses]] of pulmonary nodule include [[hamartoma]], [[granulomas]], [[Nodule|rheumatoid nodule]], and [[Metastasis|metastatic]] [[Lesion|lesions]].
==Common Differential Diagnosis==
==Differentiating Pulmonary Nodule from Other Diseases==
*The table below summarizes the findings that differentiate pulmonary nodule from other conditions that cause similar radiological findings on conventional radiograph.


{| style="border: 5px; font-size: 90%; margin: 5px; width: 1000px" align="center"
*The table below summarizes the findings that differentiate pulmonary nodule from other conditions that cause similar [[radiological]] findings on [[Computed tomography|CT scan]] of the [[chest]].<ref name="NEJM-cp">{{cite journal |author=Ost D, Fein AM, Feinsilver SH |title=Clinical practice. The solitary pulmonary nodule |journal=N. Engl. J. Med. |volume=348 |issue=25 |pages=2535–42 |year=2003 |month=June |pmid=12815140 |doi=10.1056/NEJMcp012290 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12815140&promo=ONFLNS19}}</ref><ref name="NEJM">McWilliams A, Tammemagi MC, Mayo JR, et. al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013 Sep 5;369(10):910-9. doi:10.1056/NEJMoa1214726.</ref>
! colspan="2" style="padding: 5px 5px; background: #4479BA; font-weight: bold; text-align:center;" |{{fontcolor|#FFF|'''Differential Diagnosis for Solitary Pulmonary''' <br><SMALL> Adapted from Erasmus et al. <ref name="CDC"> Solitary Pulmonary Nodule: Morphological Evaluation. http://pubs.rsna.org/doi/pdf/10.1148/radiographics.20.1.g00ja0343 Accessed on March 15, 2016 </ref></SMALL>}}
| valign="top" |
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Causes}}
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | Malignant neoplasms
| style="padding: 5px 5px; background: #F5F5F5;" |
*Bronchogenic carcinoma
*Carcinoid tumor
*Pulmonary lymphoma
*Pulmonary sarcoma
*Solitary metastases
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | Benign neoplasms
| style="padding: 5px 5px; background: #F5F5F5;" |  
*Hamartoma
*Adenoma
*Lipoma
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | Infectious inflammatory
| style="padding: 5px 5px; background: #F5F5F5;" |
*Granuloma (tuberculous/fungal)
*Nocardia infection
*Round pneumonia
*Abscess
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | Non-infectious inflammatory
| style="padding: 5px 5px; background: #F5F5F5;" |
*Rheumatoid arthritis
*Wegener's granulomatosis
*Sarcoidosis
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | Vascular
| style="padding: 5px 5px; background: #F5F5F5;" | 
*Arteriovenous malformation
*Infarction
*Hematoma
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | Congenital
| style="padding: 5px 5px; background: #F5F5F5;" | 
*Bronchial atresia
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | Miscellaneous
| style="padding: 5px 5px; background: #F5F5F5;" | 
*External object
*Pseudotumor
*Pleural thickening
|}
==Differential Diagnosis==


<small>
{|
{|
| colspan="15" |'''<small>ABBREVIATIONS''':'''N/A''': Not available , '''SOB''': Shortness of breath, '''M/C''': Most common </small><small><nowiki/></small><small><nowiki/></small>
|-
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
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* Normal
* Normal


* [[pleural friction rub]]
* [[Pleural friction rub]]
* [[egophony]]
* [[Egophony]]
* [[Rales|Crackling]] or bubbling
* [[Rales|Crackling]] or bubbling
* [[Whispered pectoriloquy]]
* [[Whispered pectoriloquy]]
* Absent [[breath sounds]]
* Absent [[breath sounds]]
| style="background: #F5F5F5; padding: 5px;" |Normal
| style="background: #F5F5F5; padding: 5px;" |
* Normal
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Single
* Single
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* <5 mm [[Nodule (medicine)|nodule]]
* <5 mm [[Nodule (medicine)|nodule]]
* [[Ground glass opacification on CT|Ground glass]]
* [[Ground glass opacification on CT|Ground glass]]
[[File: CT of ground glass lung nodule.png|x200px|thumb|CT showing Ground glass opacity nodule. (Picture courtesy: [https://en.wikipedia.org/wiki/Lung_nodule Wikipedia])]]
| style="background: #F5F5F5; padding: 5px;" |[[Fat]]
| style="background: #F5F5F5; padding: 5px;" |[[Fat]]


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* Popcorn  
* Popcorn  
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* well-defined smooth border
* Well-defined smooth border
* Growth rate > 18 months
* [[Growth rate]] > 18 months
* Cavity wall thickness of 1 mm
* [[Cavity]] wall thickness of 1 mm
[[File:Pulmonary hamartoma.jpeg|x200px|thumb|CT showing Pulmonary [[hamartoma]] with well-defined smooth border. Case courtesy of Dr Domenico Nicoletti (Picture courtesy: [https://radiopaedia.org/cases/pulmonary-hamartoma-11?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |
* N/A
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* N/A
* N/A
| style="background: #F5F5F5; padding: 5px;" |N/A
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |[[Oxygen saturation|↓ O2 Sat]]
* [[Oxygen saturation|↓ O2 Sat]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Lung cancer|Pulmonary Nodule (malignant)]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Lung cancer|Pulmonary Nodule (malignant)]]
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* Normal
* Normal


* [[pleural friction rub]]
* [[Pleural friction rub]]
* [[egophony]]
* [[Egophony]]
* [[Rales|Crackling]] or bubbling
* [[Rales|Crackling]] or bubbling
* [[Whispered pectoriloquy]]
* [[Whispered pectoriloquy]]
* Absent [[breath sounds]]
* Absent [[breath sounds]]
| style="background: #F5F5F5; padding: 5px;" |[[Cancer|Tumor cells]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Cancer|Tumor cells]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Single or multiple
* Single or multiple
* Small or > 2 cm of size
* Small or > 2 cm of size
[[File: Lungca.jpg|x200px|thumb|CT showing bronchogenic carcinoma. Case courtesy of Dr Ahmed Abdrabou (Picture courtesy: [https://radiopaedia.org/cases/bronchogenic-carcinoma-with-upper-lobe-collapse?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |[[Calcification]]
| style="background: #F5F5F5; padding: 5px;" |[[Calcification]]
* Amorphous
* [[Amorphous solid|Amorphous]]
* Punctate
* Punctate
* Reticular
* [[Reticular]]
* Stippled or eccentric
* Stippled or [[Eccentric Lesion|eccentric]]
[[Cavity]]
[[Cavity]]
[[Ulcer|Ulceration]]
[[Ulcer|Ulceration]]
[[File:Cavitatory bronchogenic lungca.jpeg|x200px|thumb|CT showing bronchogenic [[lung cancer]] with cavity Case courtesy of Dr Ahmed Abdrabou (Picture courtesy: [https://www.wikidoc.org/index.php/File:Cavitatory_bronchogenic_lungca.jpeg Radiopaedia])]]
*  
*  
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Spiculated border
* Spiculated border
* Rapid growth rate (Doubling time 1-18 months)
* Rapid growth rate ([[Doubling time]] 1-18 months)
* [[Cavity]] wall thickness over 15 mm
* [[Cavity]] wall thickness over 15 mm
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
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* No [[necrosis]]   
* No [[necrosis]]   
*   
*   
| style="background: #F5F5F5; padding: 5px;" |[[Biopsy]] and [[histopathology]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |[[Oxygen saturation|↓ O2 Sat]]
* [[Biopsy]] and [[histopathology]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Oxygen saturation|↓ O2 Sat]]
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Diseases
!Diseases
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* [[Fatigue]]
* [[Fatigue]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Decreased [[Breath sounds|breath sound]]
* [[Decreased breath sounds|Decreased breath sound]]
* Bronchial [[Breath sounds|breath sound]]
* [[Breath sound|Bronchial breath sound]]
* [[Crackles|Inspiratory crackles]]
* [[Crackles|Inspiratory crackles]]
* [[Crepitations|Localised crepitations]]
* [[Crepitations|Localised crepitations]]
| style="background: #F5F5F5; padding: 5px;" |[[Microorganism|Causative agents]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Microorganism|Causative agents]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Vary in size
* Vary in size
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* [[Consolidation (medicine)|Consolidation]]
* [[Consolidation (medicine)|Consolidation]]
* [[Cavity]] persists longer than [[Consolidation (medicine)|consolidation]]
* [[Cavity]] persists longer than [[Consolidation (medicine)|consolidation]]
[[File: Ct Lung abscess.jpeg|x200px|thumb|CT showing lung abscess Case courtesy of Dr Vijay Mistry (Picture courtesy: [https://radiopaedia.org/cases/septic-pulmonary-emboli?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |.
| style="background: #F5F5F5; padding: 5px;" |.
* The wall of the [[abscess]] is typically thick and the [[luminal]] surface irregular
 
* The wall of the [[abscess]] is typically thick and the [[luminal]] surface is irregular
* [[Bronchial vessels|Bronchial vessels and]] [[Bronchus|bronchi]] are truncated
* [[Bronchial vessels|Bronchial vessels and]] [[Bronchus|bronchi]] are truncated
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
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* [[Neutrophil|Neutrophils]]
* [[Neutrophil|Neutrophils]]
* [[Dilation|Dilated]] [[Blood vessel|blood vessels]]
* [[Dilation|Dilated]] [[Blood vessel|blood vessels]]
* [[Inflammation|Inflammatory]] [[Edema|oedema]]
* [[Inflammation|Inflammatory]] [[edema]]
| style="background: #F5F5F5; padding: 5px;" |[[Histopathology]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |[[Clubbing|Clubbing of finger]]
* [[Histopathology]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Clubbing|Clubbing of finger]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Septic emboli|Septic pulmonary]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Septic emboli|Septic pulmonary]]
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| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Chest pain]]
* [[Chest pain]]
* Primary infection (M/C right heart [[endocarditis]])
* Primary [[infection]] (M/C right heart [[endocarditis]])
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[S2|Prominent P2 component of second heart sound]]  
* [[S2|Prominent P2 component of second heart sound]]  
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* [[Crackles]]
* [[Crackles]]
* [[Pleural friction rub]]
* [[Pleural friction rub]]
| style="background: #F5F5F5; padding: 5px;" |N/A
| style="background: #F5F5F5; padding: 5px;" |
* N/A
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Multiple peripheral [[Nodule (medicine)|nodules]]
* Multiple peripheral [[Nodule (medicine)|nodules]]
* Size 0.5– 3.5 cm
* Size 0.5 - 3.5 cm
* Variable shapes
* Variable shapes
[[File: Multiple septic emboli.jpg|x200px|thumb|CT of a patient with angioinvasive [[aspergillosis]] Case courtesy of Dr Ahmed Abdrabou (Picture courtesy: [https://radiopaedia.org/cases/septic-pulmonary-emboli?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Central low attenuation
* Central low attenuation
* Feeding [[Blood vessel|vessels]]
* Feeding [[Blood vessel|vessels]]
* Pleura based wedge-shaped lesions
* [[Pleural cavity|Pleura]] based wedge-shaped [[Lesion|lesions]]
[[File:Septic pul emboli.jpg|x200px|thumb|CT of a patient with angioinvasive [[aspergillosis]] Case courtesy of Dr Ahmed Abdrabou (Picture courtesy: [https://radiopaedia.org/cases/septic-pulmonary-emboli?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Air bronchogram  
* Air bronchogram  
* [[Abscess]] or infection related changes at the primary focus
* [[Abscess]] or [[infection]] related changes at the primary focus
| style="background: #F5F5F5; padding: 5px;" |
* N/A
| style="background: #F5F5F5; padding: 5px;" |
* [[Culture media|Culture]] and [[Sensitivity (tests)|sensitivity]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* N/A
* N/A
| style="background: #F5F5F5; padding: 5px;" |[[Culture media|Culture]] and [[Sensitivity (tests)|sensitivity]]
| style="background: #F5F5F5; padding: 5px;" |N/A
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Mycosis|Fungal]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Mycosis|Fungal]]
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* History of travel
* History of travel
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Decreased [[Breath sounds|breath sound]]
* [[Breath sounds|Decreased breath sound]]
* [[Rales]]
* [[Rales]]


* [[Crackles]]
* [[Crackles]]
* [[Pleural friction rub]]
* [[Pleural friction rub]]
| style="background: #F5F5F5; padding: 5px;" |KOH stain: Fungi
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Multiple nodules
* [[KOH test|KOH stain]]: [[Fungus|Fungi]]
* Size 0.5– 3 cm
| style="background: #F5F5F5; padding: 5px;" |
* nodules surrounded by ground-glass opacity/halo
* Multiple [[Nodule (medicine)|nodules]]
* Size 0.5 - 3 cm
* [[Nodules]] surrounded by [[Ground glass opacification on CT|ground-glass opacity]]/halo
[[File: Angioinvasive aspergilosis.jpg|x200px|thumb|CT of a patient with angioinvasive [[aspergillosis]] Case courtesy of Assoc Prof Frank Gaillard (Picture courtesy: [https://search.creativecommons.org/photos/c4b723fe-95e5-431c-a910-3a9140348dba Creativecommons])]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Cavity]]  
* [[Cavity]]  
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Halo sign in [[aspergillosis]]
* Halo sign in [[aspergillosis]]
* Patchy infiltrate
* Patchy [[infiltrate]]
* Consolidation
* [[Consolidation (medicine)|Consolidation]]
* [[Mediastinal lymphadenopathy|Mediastinal adenopathy]]
* [[Mediastinal lymphadenopathy|Mediastinal adenopathy]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Causative agent
* [[Microorganism|Causative agent]]
| style="background: #F5F5F5; padding: 5px;" |[[Culture and sensitivity]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |N/A
* [[Culture media|Culture]] and [[Sensitivity (tests)|sensitivity]]
| style="background: #F5F5F5; padding: 5px;" |
* N/A
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Parasitism|Parasites]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Parasitism|Parasites]]
<ref name="pmid20880867">{{cite journal |vauthors=Kunst H, Mack D, Kon OM, Banerjee AK, Chiodini P, Grant A |title=Parasitic infections of the lung: a guide for the respiratory physician |journal=Thorax |volume=66 |issue=6 |pages=528–36 |date=June 2011 |pmid=20880867 |doi=10.1136/thx.2009.132217 |url=}}</ref>  
<ref name="pmid20880867">{{cite journal |vauthors=Kunst H, Mack D, Kon OM, Banerjee AK, Chiodini P, Grant A |title=Parasitic infections of the lung: a guide for the respiratory physician |journal=Thorax |volume=66 |issue=6 |pages=528–36 |date=June 2011 |pmid=20880867 |doi=10.1136/thx.2009.132217 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +/-
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* [[Wheeze]]
* [[Wheeze]]
* [[Urticaria]]
* [[Urticaria]]
* Rarely, [[anaphylaxis]]
*[[Anaphylaxis]] (rarely)
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Decreased [[Breath sounds|breath sound]]
* [[Breath sounds|Decreased breath sound]]
* Rales
* [[Rales]]


* [[Crackles]]
* [[Crackles]]
| style="background: #F5F5F5; padding: 5px;" |N/A
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Cyst|Cysts]]: Single or multiple well-defined homogenous
* N/A
* [[Pulmonary nodule|Coin lesion]]: 1–3 cm
| style="background: #F5F5F5; padding: 5px;" |
* [[Cyst|Cysts]]: Single or multiple well-defined [[Homogeneity|homogenous]]
* Coin [[lesion]]: 1 - 3 cm
| style="background: #F5F5F5; padding: 5px;" |[[Cyst]]:  
| style="background: #F5F5F5; padding: 5px;" |[[Cyst]]:  
* Fluid or gas
* Fluid or gas
* [[Parasitic worm|Worm]]
* [[Parasitic worm|Worm]]
[[Pulmonary nodule|Coin lesion]]:  
 
Coin [[lesion]]:  
* Central [[Necrosis|necrotic]]
* Central [[Necrosis|necrotic]]
* [[Granuloma|Granulomatous]] reaction and fibrous wall
* [[Granuloma|Granulomatous]] reaction and fibrous wall
Line 339: Line 314:
* [[Parasitic worm|Worm]]
* [[Parasitic worm|Worm]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[larvae]] or eggs
* [[Larva migrans|Larvae]] or [[Eggs per gram|eggs]]
 
[[File:Loa loa.jpg|x200px|thumb|Microfilaria(larva) of loa loa (Picture courtesy: [https://search.creativecommons.org/photos/c4b723fe-95e5-431c-a910-3a9140348dba Creativecommons])]]
*
*
| style="background: #F5F5F5; padding: 5px;" |Visualization of [[Parasites|parasite]], egg or larvae
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |N/A
* Visualization of [[Parasites|parasite]], [[Eggs per gram|egg]] or [[Larva migrans|larvae]]
| style="background: #F5F5F5; padding: 5px;" |
* N/A
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Diseases
!Diseases
Line 380: Line 357:
* [[Rales]]
* [[Rales]]
* [[Rhonchi]]
* [[Rhonchi]]
* Bronchial breath sounds
* [[Breath sounds|Bronchial breath sounds]]
| style="background: #F5F5F5; padding: 5px;" |AFB+
| style="background: #F5F5F5; padding: 5px;" |
* AFB+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Micronodules in the [[subpleural]] region and peribronchovascular interstitium
* Micronodules in the [[subpleural]] region and peribronchovascular interstitium
Line 388: Line 366:
* [[Cavity]]
* [[Cavity]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Superinfected]] [[Cavity|cavities]] shows air-fluid level
* [[Superinfection|Superinfected]] [[Cavity|cavities]] shows air-fluid level
[[File: Cavitary tb.jpg|x200px|thumb|CT showing cavitating lesion with air-fluid level. Case courtesy of Dr Ayush Goel  (Picture courtesy: [https://radiopaedia.org/cases/pulmonary-tuberculosis-9?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Fluffy upper zone shadowing
* Fluffy upper zone shadowing
* Interlobular septal thickening
* Interlobular septal thickening
* Homogeneous and dense [[Consolidation (medicine)|consolidation]]
*[[Homogenization|Homogeneous]] and dense [[Consolidation (medicine)|consolidation]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Granuloma|Granulomas]]: [[necrotizing]]/non-necrotizing
* [[Granuloma|Granulomas]]: [[necrotizing]]/non-necrotizing
* [[Langhans giant cell|Langhans giant cells]]
* [[Langhans giant cell|Langhans giant cells]]
* [[Caseous necrosis]]
* [[Caseous necrosis]]
| style="background: #F5F5F5; padding: 5px;" |[[Growth medium|Culture]] and [[Sensitivity (tests)|sensitivity]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |N/A
* [[Growth medium|Culture]] and [[Sensitivity (tests)|sensitivity]]
| style="background: #F5F5F5; padding: 5px;" |
* N/A
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Chronic inflammatory conditions
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic inflammatory|Chronic inflammatory conditions]]
[[Granulomatosis with polyangiitis|(Granulomatosis with polyangiitis)]]
[[Granulomatosis with polyangiitis|(Granulomatosis with polyangiitis)]]


Line 415: Line 396:
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Pleural friction rub]]
* [[Pleural friction rub]]
* Absent breath sound
* Absent [[Breath sounds|breath sound]]
* [[Crackles]]
* [[Crackles]]
| style="background: #F5F5F5; padding: 5px;" |N/A
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Multiple round lesions
* N/A
* Size 0.5 to 10 cm  
| style="background: #F5F5F5; padding: 5px;" |
* Multiple round [[Lesion|lesions]]
* Size 0.5 - 10 cm
[[File:Lung Granulomatosis with polyangiitis.jpeg|x200px|thumb|CT showing multiple lung nodules bilaterally Case courtesy of Dr Abdallah Al Khateeb (Picture courtesy: [https://radiopaedia.org/cases/granulomatosis-with-polyangiitis-3?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Patchy or diffuse ground-glass opacities, or both
* Patchy or diffuse [[Ground glass opacification on CT|ground-glass opacities]], or both
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Cavity]]
* [[Cavity]]
Line 429: Line 412:
* [[Atelectasis]]
* [[Atelectasis]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Pathologic triad of [[Granuloma|granulomatous]] [[inflammation]], [[vasculitis]], and [[necrosis]]
* [[Pathological|Pathologic]] triad of [[Granuloma|granulomatous]] [[inflammation]], [[vasculitis]], and [[necrosis]]
| style="background: #F5F5F5; padding: 5px;" |[[Biopsy]]
[[File: Granulomatosis with polyangiitis histo.jpg|x200px|thumb|Micrograph of Granulomatosis with polyangiitis (Picture courtesy: [https://en.wikipedia.org/wiki/Granulomatosis_with_polyangiitis#/media/File:Wegener's_granulomatosis_-b-_intermed_mag.jpg Wikipedia])]]
| style="background: #F5F5F5; padding: 5px;" |[[Anti-neutrophil cytoplasmic antibody|c-ANCA]]
| style="background: #F5F5F5; padding: 5px;" |
 
* [[Biopsy]]
[[Anti-neutrophil cytoplasmic antibody|p-ANCA]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Anti-neutrophil cytoplasmic antibody|c-ANCA]]
* [[Anti-neutrophil cytoplasmic antibody|p-ANCA]]
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Diseases
!Diseases
Line 467: Line 452:
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Bruit]]
* [[Bruit]]
| style="background: #F5F5F5; padding: 5px;" |[[Red blood cell|RBCs]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Solitary or multiple nodules
* [[Red blood cell|RBCs]]
| style="background: #F5F5F5; padding: 5px;" |
* Solitary or multiple [[Nodule (medicine)|nodules]]
* Round, oval, or polycyclic  
* Round, oval, or polycyclic  
* Size 1 to 5 cm
* Size 1 - 5 cm
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Feeding [[Pulmonary artery|pulmonary arteries]] and draining [[pulmonary veins]]
* Feeding [[Pulmonary artery|pulmonary arteries]] and draining [[pulmonary veins]]
[[File: PUL AVM CT.jpeg|x200px|thumb|CT showing pulmonary [[arteriovenous malformation]] Case courtesy of Dr Vikas Shah (Picture courtesy: [https://radiopaedia.org/cases/pulmonary-arteriovenous-malformation-8?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Well-defined borders
* Well-defined borders
* [[Lung|Lower and middle third of the lung]]
* [[Lung|Lower and middle third of the lung]]
[[File: 7181cc666b496fb54795332af08c45 big gallery.jpeg|x200px|thumb|CT showing pulmonary [[arteriovenous malformation]] Case courtesy of Dr Vikas Shah (Picture courtesy: [https://radiopaedia.org/cases/pulmonary-arteriovenous-malformation-8?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Not done
* Not done
| style="background: #F5F5F5; padding: 5px;" |[[Pulmonary angiography]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |N/A
* [[Pulmonary angiography]]
| style="background: #F5F5F5; padding: 5px;" |
*Solitary rounded opacity on X-ray
[[File: PUL MVM XRAY.jpeg|x200px|thumb|X-ray showing pulmonary [[arteriovenous malformation]] Case courtesy of Dr Vikas Shah (Picture courtesy: [https://radiopaedia.org/cases/pulmonary-arteriovenous-malformation-8?lang=gb Radiopaedia])]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumoconiosis]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumoconiosis]]
Line 493: Line 484:
* Fine [[crackles]]  
* Fine [[crackles]]  
* [[Rhonchi]]
* [[Rhonchi]]
* Bronchial breath sounds
* [[Breath sounds|Bronchial breath sounds]]
* Expiratory [[wheezing]]
* [[Wheeze|Expiratory wheezing]]
* [[Egophony]]
* [[Egophony]]
* [[Bronchophony]]
* [[Bronchophony]]
| style="background: #F5F5F5; padding: 5px;" |[[Inorganic compound|Inorganic particle]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Inorganic compound|Inorganic particle]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Solitary or multiple nodules
* Solitary or multiple nodules
* Size 1 - 10 cm
* Size 1 - 10 cm
* In the upper lobes
* In the upper [[Lobe (anatomy)|lobes]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* N/A
* N/A
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Massive [[fibrosis]] or [[conglomerate]] masses
* Massive [[fibrosis]] or [[conglomerate]] [[Tumor|masses]]
* Small [[Nodule (medicine)|nodular]] [[opacities]]
* Small [[Nodule (medicine)|nodular]] [[opacities]]
* [[lymphadenopathy]] [[Calcification|eggshell calcification]]
*Pleural plaques
* [[Lymphadenopathy]], [[Calcification|eggshell calcification]]
[[File: Pneumoconiosis resulting from the inhalation of asbestos fibers.jpg|x200px|thumb|X-ray showing pleural plaques in a patient with [[asbestosis]] (Picture courtesy: [https://medpix.nlm.nih.gov/search?allen=true&allt=true&alli=true&query=Pneumoconiosis Medpix])]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Calcification]]
* [[Calcification]]
Line 513: Line 507:
* Dense [[collagen]]
* Dense [[collagen]]
* [[Cancer|Malignant cells]]
* [[Cancer|Malignant cells]]
| style="background: #F5F5F5; padding: 5px;" |[[Computed tomography|CT scan]]
*[[Ferruginous bodies]]
| style="background: #F5F5F5; padding: 5px;" |N/A
[[File:1024px-Asbestosis high mag histology.jpg|x200px|thumb|Pneumoconiosis due to [[asbestosis]] showing  [[ferruginous bodies]] (Picture courtesy: [https://en.wikipedia.org/wiki/Pneumoconiosis#/media/File:Asbestosis_high_mag.jpg Wikipedia])]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Computed tomography|CT scan]]
[[File: Pneumoconiosis CT.jpeg|x200px|thumb| CT scan showing multifocal areas of ground-glass opacities in a patient with hard-metal pneumoconiosis. Case courtesy of Dr Azza Elgendy (Picture courtesy: [https://radiopaedia.org/cases/hard-metal-pneumoconiosis-1?lang=gb Radiopaedia])]]
| style="background: #F5F5F5; padding: 5px;" |
* N/A
|-
| colspan="15" |'''<small>ABBREVIATIONS''':'''N/A''': Not available , '''SOB''': Shortness of breath, '''M/C''': Most common </small><small><nowiki/></small><small><nowiki/></small>
|}
|}
</small>
'''<small>ABBREVIATIONS''':
'''N/A''': Not available , '''SOB''': Shortness of breath, '''M/C''': Most common </small><small><nowiki/></small><small><nowiki/></small>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 00:49, 22 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Trusha Tank, M.D.[2], Joanna Ekabua, M.D. [3], Maria Fernanda Villarreal, M.D. [4]

Overview

Pulmonary nodule may be differentiated according to imaging (size, border characteristics, and attenuation), histological, and clinical features, from other diseases that demonstrate similar imaging findings. Common differential diagnoses of pulmonary nodule include hamartoma, granulomas, rheumatoid nodule, and metastatic lesions.

Differentiating Pulmonary Nodule from Other Diseases

  • The table below summarizes the findings that differentiate pulmonary nodule from other conditions that cause similar radiological findings on CT scan of the chest.[1][2]
ABBREVIATIONS:N/A: Not available , SOB: Shortness of breath, M/C: Most common
Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical exam
Lab Findings CT scan Histopathology
Productive cough Hemoptysis Weight loss SOB Fever Other Auscultation Sputum analysis Nodule Nodule content Other findings
Pulmonary Nodule(benign)

[3]

- - - - -
  • N/A
  • Normal
  • Normal
CT showing Ground glass opacity nodule. (Picture courtesy: Wikipedia)
Fat

Calcification

Types:

  • Central dense nidus
  • Diffuse solid
  • Laminated
  • Popcorn
CT showing Pulmonary hamartoma with well-defined smooth border. Case courtesy of Dr Domenico Nicoletti (Picture courtesy: Radiopaedia)
  • N/A
  • N/A
Pulmonary Nodule (malignant)

[3][4]

++ ++ ++ + -
  • Normal
  • Single or multiple
  • Small or > 2 cm of size
CT showing bronchogenic carcinoma. Case courtesy of Dr Ahmed Abdrabou (Picture courtesy: Radiopaedia)
Calcification

Cavity Ulceration

CT showing bronchogenic lung cancer with cavity Case courtesy of Dr Ahmed Abdrabou (Picture courtesy: Radiopaedia)
  • Spiculated border
  • Rapid growth rate (Doubling time 1-18 months)
  • Cavity wall thickness over 15 mm
Diseases Productive cough Hemoptysis Weight loss SOB Fever Other Auscultation Sputum analysis Nodule Content Other findings Histopathology Gold standard Additional findings
Abscess

[5]

++ - - + ++
  • Vary in size
  • Round in shape
CT showing lung abscess Case courtesy of Dr Vijay Mistry (Picture courtesy: Radiopaedia)
.
Septic pulmonary

emboli

[6]

- - - ++ ++
  • N/A
  • Multiple peripheral nodules
  • Size 0.5 - 3.5 cm
  • Variable shapes
CT of a patient with angioinvasive aspergillosis Case courtesy of Dr Ahmed Abdrabou (Picture courtesy: Radiopaedia)
CT of a patient with angioinvasive aspergillosis Case courtesy of Dr Ahmed Abdrabou (Picture courtesy: Radiopaedia)
  • N/A
  • N/A
Fungal

infection

[7]

+/- + - + +
CT of a patient with angioinvasive aspergillosis Case courtesy of Assoc Prof Frank Gaillard (Picture courtesy: Creativecommons)
  • N/A
Parasites

[8]

+/- +/- +/- _ +
  • N/A
Cyst:

Coin lesion:

Microfilaria(larva) of loa loa (Picture courtesy: Creativecommons)
  • N/A
Diseases Productive cough Hemoptysis Weight loss SOB Fever Other Auscultation Sputum analysis Nodule Content Other findings Histopathology Gold standard Additional findings
Mycobacterial infections

[9][10]

+ + + ++ +/-
  • AFB+
  • Micronodules in the subpleural region and peribronchovascular interstitium
  • Fluffy upper zone shadowing
  • Cavity
CT showing cavitating lesion with air-fluid level. Case courtesy of Dr Ayush Goel (Picture courtesy: Radiopaedia)
  • N/A
Chronic inflammatory conditions

(Granulomatosis with polyangiitis)

[11]

+/- + - + -
  • N/A
  • Multiple round lesions
  • Size 0.5 - 10 cm
CT showing multiple lung nodules bilaterally Case courtesy of Dr Abdallah Al Khateeb (Picture courtesy: Radiopaedia)
Micrograph of Granulomatosis with polyangiitis (Picture courtesy: Wikipedia)
Diseases Productive cough Hemoptysis Weight loss SOB Fever Other Auscultation Sputum analysis Nodule Content Other findings Histopathology Gold standard Additional findings
Pulmonary AVMs

[12]

- +/- - + -
  • Solitary or multiple nodules
  • Round, oval, or polycyclic
  • Size 1 - 5 cm
CT showing pulmonary arteriovenous malformation Case courtesy of Dr Vikas Shah (Picture courtesy: Radiopaedia)
CT showing pulmonary arteriovenous malformation Case courtesy of Dr Vikas Shah (Picture courtesy: Radiopaedia)
  • Not done
  • Solitary rounded opacity on X-ray
X-ray showing pulmonary arteriovenous malformation Case courtesy of Dr Vikas Shah (Picture courtesy: Radiopaedia)
Pneumoconiosis + - + + -
  • Solitary or multiple nodules
  • Size 1 - 10 cm
  • In the upper lobes
  • N/A
X-ray showing pleural plaques in a patient with asbestosis (Picture courtesy: Medpix)
Pneumoconiosis due to asbestosis showing ferruginous bodies (Picture courtesy: Wikipedia)
CT scan showing multifocal areas of ground-glass opacities in a patient with hard-metal pneumoconiosis. Case courtesy of Dr Azza Elgendy (Picture courtesy: Radiopaedia)
  • N/A
ABBREVIATIONS:N/A: Not available , SOB: Shortness of breath, M/C: Most common

References

  1. Ost D, Fein AM, Feinsilver SH (2003). "Clinical practice. The solitary pulmonary nodule". N. Engl. J. Med. 348 (25): 2535–42. doi:10.1056/NEJMcp012290. PMID 12815140. Unknown parameter |month= ignored (help)
  2. McWilliams A, Tammemagi MC, Mayo JR, et. al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013 Sep 5;369(10):910-9. doi:10.1056/NEJMoa1214726.
  3. 3.0 3.1 Khan AN, Al-Jahdali HH, Irion KL, Arabi M, Koteyar SS (October 2011). "Solitary pulmonary nodule: A diagnostic algorithm in the light of current imaging technique". Avicenna J Med. 1 (2): 39–51. doi:10.4103/2231-0770.90915. PMC 3507065. PMID 23210008.
  4. Li J, Xia T, Yang X, Dong X, Liang J, Zhong N, Guan Y (April 2018). "Malignant solitary pulmonary nodules: assessment of mass growth rate and doubling time at follow-up CT". J Thorac Dis. 10 (Suppl 7): S797–S806. doi:10.21037/jtd.2018.04.25. PMC 5945695. PMID 29780626.
  5. Kuhajda I, Zarogoulidis K, Tsirgogianni K, Tsavlis D, Kioumis I, Kosmidis C, Tsakiridis K, Mpakas A, Zarogoulidis P, Zissimopoulos A, Baloukas D, Kuhajda D (August 2015). "Lung abscess-etiology, diagnostic and treatment options". Ann Transl Med. 3 (13): 183. doi:10.3978/j.issn.2305-5839.2015.07.08. PMC 4543327. PMID 26366400.
  6. Chang E, Lee KH, Yang KY, Lee YC, Perng RP (2009). "Septic pulmonary embolism associated with a peri-proctal abscess in an immunocompetent host". BMJ Case Rep. 2009. doi:10.1136/bcr.07.2008.0592. PMC 3029652. PMID 21686732.
  7. Chong, Semin; Lee, Kyung Soo; Yi, Chin A; Chung, Myung Jin; Kim, Tae Sung; Han, Joungho (2006). "Pulmonary fungal infection: Imaging findings in immunocompetent and immunocompromised patients". European Journal of Radiology. 59 (3): 371–383. doi:10.1016/j.ejrad.2006.04.017. ISSN 0720-048X.
  8. Kunst H, Mack D, Kon OM, Banerjee AK, Chiodini P, Grant A (June 2011). "Parasitic infections of the lung: a guide for the respiratory physician". Thorax. 66 (6): 528–36. doi:10.1136/thx.2009.132217. PMID 20880867.
  9. Ryu YJ (April 2015). "Diagnosis of pulmonary tuberculosis: recent advances and diagnostic algorithms". Tuberc Respir Dis (Seoul). 78 (2): 64–71. doi:10.4046/trd.2015.78.2.64. PMC 4388902. PMID 25861338.
  10. Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  11. Kubaisi B, Abu Samra K, Foster CS (May 2016). "Granulomatosis with polyangiitis (Wegener's disease): An updated review of ocular disease manifestations". Intractable Rare Dis Res. 5 (2): 61–9. doi:10.5582/irdr.2016.01014. PMC 4869584. PMID 27195187.
  12. Khurshid I, Downie GH (April 2002). "Pulmonary arteriovenous malformation". Postgrad Med J. 78 (918): 191–7. PMC 1742331. PMID 11930021.