Differential Diagnosis for Erythema Nodosum

By Sharon Shaw,2014-06-26 19:59
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Differential Diagnosis for Erythema Nodosum ...

    Differential Diagnosis for…

    Cardiac External Medicine Hematological Head Dyspnea Alopecia Abnormal hemostasis Delirium Chest Pain Acanthosis nigricans Hypercoagulability Dementia Palpitations Clubbing Hemolytic Anemia Ataxia Cardiac Enlargement Cyanosis Thrombocytopenia Asterixis Murmurs Erythema Nodosum Thrombocytosis Amnesia Orthostatic Hypotension Subcutaneous Nodules Lymphocytosis Anisocoria Pulse Pressure Abnormalities Vesicubullous lesions Rheumatoid Factor Epistaxis Elevated JVP Nodules and Arthritis Hyperviscocity Headaches Paradoxical Splitting Exanthems Eosinophilia Seizures Continuous Murmurs Hand and Foot Rash Syncope

     Splinter hemorrhages GI/Abdominal Vertigo Hypertension Livedo reticularis Abdominal Pain Congestive Heart Failure Yellow discoloration Abdominal distention Neck (Acute) Mechanical obstruction Cervical lymphadenopathy

     Endo GI bleed Dysphagia / Odynophagia Lungs Small testes Vomiting Cough Delayed puberty Diarrhea Neuro Wheezing Hirsutism Mononeuritis Multiplex Hemoptysis Liver

    Cavitary lesion of lungs Ascites

    Pleural Effusion OB/Gyn Splenomegaly

    Cyanosis Postmenopausal bleeding Cysts



    Musculoskeletal Hematuria

    Joint Pain (see joint pathology)

    Muscle Weakness (see myopathy)

    Back Pain

    Electrolyte Abnormalities (see other)


    Failure to Thrive

    Mental Retardation

    Precocious puberty / Late Puberty

Ddx for opportunistic pathogens in AIDS patients

    Causes of Dyspnea

Heart disease

    Left ventricular failure

    Restrictive cardiomyopathy

    Constrictive pericarditis

    Pulmonary venous obstruction

    Mitral stenosis

    Cor triatriatum

    Left atrial myxoma

    Left atrial thrombus


    Lung disease

    Obstructive airways disease

    Chronic obstructive pulmonary disease


    Restrictive lung disease

    Interstitial or diffuse alveolar lung disease

    Disorders of chest wall and bellows function



    Neuromuscular disease


    Vascular disease

    Pulmonary embolism

    Primary pulmonary hypertension

    High altitude exposure Anemia

    Anxiety (hyperventilation syndrome)

    Causes of Chest Pain

Heart disease

    Angina pectoris

    Atheromatous coronary artery disease

    Nonatheromatous coronary artery disease

    Aortic stenosis (AS)

    Aortic insufficiency (AI)

    Idiopathic hypertrophic subaortic stenosis (HOCM, IHSS)

    Myocardial infarction

    Congestive cardiomyopathy

    Pulmonary hypertension

    Mitral valve prolapse (click-murmur) syndrome (MVP)


    Dissection of the aorta

    Pulmonary disease

    Pulmonary embolism





    Collagen disease


    Atelectasis mechanism?

    Musculoskeletal disease


    Costochondritis (Tietze syndrome)


    Intravertebral disc disease

    Thoracic outlet syndrome

    Muscle spasm


    Metastatic tumor or hematologic (leukemia) or plasma cell (myeloma) malignancy Neural disease

    Intercostal neuritis

    Herpes zoster

    Gastrointestinal disorders ("referred" chest pain)

    Hiatal hernia



    Ulcer disease

    Bowel disease


    Emotional duress or anxiety (e.g., neurocirculatory asthenia, Da Costa syndrome)

    Causes of Hemoptysis


    Massive Hemoptysis ? 600 ml in 24 hrs (place affected lung in dependent position, ?rigid

    bronchoscopy, ?intubation)

    Most common in US: bronchitis, lung cancer

    Hemoptysis + acute pleuritic pain ? PE

    Hemoptysis + chronic copious sputum ? bronchiectasis


    Pulmonary venous hypertension

    Left ventricular failure

    Mitral stenosis

    Eisenmenger syndrome Pulmonary [see endobronchial Ddx]


    stBronchitis (1)

    Bronchiectasis ndTb (2)


    Abscess rdLung cancer (3)

    Trauma or foreign body

    Alveolar hemorrhage


    Rupture of AV fistula

    Thoracic aortic aneurysm

    Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) Primary pulmonary hypertension

    Pulmonary embolism

    Goodpasture’s syndrome Arthritides

    Polyarteritis nodosa (PAN)

    Wegener's granulomatosis


    Bleeding diathesis

    Endobronchial Lesions

Endobronchial carcinoma

    Metastatic endobronchial tumor


    Endometrial or ovarian carcinoma

    Thyroid carcinoma

    Renal cell carcinoma

    Kaposi’s sarcoma

    Calcified carcinoid tumor

    Endometrial endometriosis

    Benign tumor or pyogenic granuloma

    Granulation tissue

    Response to foreign body irritation


    Vasculitis, Wegener’s Lymphomatoid granulomatosis


    Fungal infection

    aspergillosis, phaeohyphomycosis, sporotrichosis, blastomycosis, histoplasmosis,




    Causes of Palpitations

Extra systoles

    Atrial premature beats

    AV junctional (nodal) premature beats

    Ventricular premature beats




    Sinus tachycardia

    Paroxysmal supraventricular tachycardia

    AV junctional tachycardia

    Atrial flutter


    Atrial fibrillation

    Paroxysmal supraventricular tachycardia or atrial flutter with block

    Multifocal atrial tachycardia Ventricular tachycardia


    Sinus bradycardia

    Sinus arrest

    2ndrd or 3 degree AV block

    Conditions associated with increased force of cardiac contraction




    Certain drugs, including catecholamines and cardiac glycosides

    Anxiety states

    Causes of Cardiac Enlargement

Congestive heart failure

    Valvular heart disease

    Volume or pressure overload (e.g., L to R shunts, systemic arterial hypertension)

    Heart muscle disease (ischemia or cardiomyopathy)

    High-output failure

    Ventricular aneurysm

    Large stroke volume

    Athlete's heart

    Complete heart block

    Pericardial effusion

    Cardiac cysts and tumors

    Absence of the pericardium

    Common Causes of Murmurs

Valvular heart disease


    Insufficiency of congenital or acquired etiology Nonvalvular outflow obstruction

    Supravalvular and subvalvular outflow obstruction

    Idiopathic hypertrophic subaortic stenosis (HOCM, IHSS) Shunts (extracardiac and intracardiac)

    Complex congenital heart disease producing turbulence

    Physiologic murmurs

    Hyperdynamic states





    AV fistula


    Flow across normal valves in high-volume states

    Diastolic rumble in mitral and tricuspid regurgitation,

    atrial and ventricular septal defect, patent ductus arteriosus

    Complete heart block

    Austin Flint murmur of aortic regurgitation

    Innocent murmurs of childhood

    Anatomic distortion producing turbulence

    Straight back syndrome

    Pectus excavatum

    Chest deformity

    High to low pressure communication

    Ruptured sinus of Valsalva aneurysm

    Coronary fistula

    Anomalous origin of left coronary artery from pulmonary artery

    AV fistula

    Arteriopulmonary connection

    Dilatation or stenosis of large or small vessels

    Aneurysm or dilatation of aorta or pulmonary artery


    Peripheral pulmonary stenosis

    Atherosclerotic vascular narrowing

    Pulmonary embolism

    Alteration of arterial or venous flow in nonconstricted vessels

    Venous hum

    Mammary soufflé

    High brachiocephalic flow in children

    High flow in collateral vessels

    Intercostal/bronchial collaterals in coarctation of aorta, pulmonic stenosis, or atresia

    Aortic regurgitation

    Sounds resembling murmurs

    Fusion of S3 and S4 gallops

    Prolonged gallop sounds

    Pericardial and pleural friction rubs

Causes of Orthostatic Hypotension




    Drugs (e.g., tranquilizers, vasodilators)

    CNS disease (e.g., syringomyelia, tabes dorsalis)

    Addison's disease


    Wernicke syndrome


    Diabetes mellitus

    Primary autonomic insufficiency

    After sympathectomy

    Physical deconditioning

Continuous Murmurs

Location of Murmur

     Differential Diagnosis

    First to second left intercostal spaces (and under left clavicle) Patent ductus arteriosus

Second to fourth left intercostal spaces Aorticopulmonary septal defect

    Usually best heard in the second to third left intercostal spaces; Surgical shunts, such as aortopulmonary occasionally may be best heard at the right of the sternum in the anastomoses same area

    Usually best heard along the lower left sternal border, although it Rupture of sinus of Valsalva aneurysm

    may be audible over the entire precordium

    Audible over the left precordium Coronary AV fistulae

    May be audible anywhere that they occur AV fistulae

Pulse Pressure Abnormalities

    Increased Pulse Pressure Narrow Pulse Pressure

Sinus bradycardia Severe heart failure (please understand how)

Complete heart block Shock

Emotion Aortic stenosis (usually occurs but is not always present)

    Exercise Hypovolemia

    Aortic regurgitation Vasoconstrictive agents

AV fistulae





    Inelastic aorta (elderly patients)

    Abnormal connections between aorta and pulmonary

    artery (patent ductus arteriosus, aorticopulmonary


    Rupture of sinus of Valsalva aneurysm

Arterial Pulse Abnormalities

Abnormality Description

     Anacrotic pulse A small, slowly rising pulse with a notch on the ascending

     limb, such that there are two deflections on the upstroke of the


    Bisferiens pulse Two palpable systolic peaks of almost equal height

    Dicrotic pulse A second peak during diastole

Waterhammer pulse Characterized by rapid and sudden systolic expansion

Idiopathic hypertrophic subaortic stenosis A carotid pulse with a very rapid upstroke. sometimes having a

    pulse bisferiens quality

Elevated Jugular Venous Pressure (JVP)

Right ventricular failure

    Vascular pulmonic stenosis

    Infundibular pulmonary stenosis

    Pulmonary hypertension

    Tricuspid stenosis or insufficiency


    Pericardial tamponade

    Constrictive pericarditis

Superior vena caval obstruction

Paradoxical Splitting of the Second Heart Sound

Elevated PAP?

    Left bundle branch block

    Right ventricular ectopic beats

    Right ventricular pacing

    Angina pectoris

    Left ventricular failure

    Left ventricular outflow obstruction

    Severe systemic hypertension

    Note: Paradoxical splitting occurs in some but not all patients with these abnormalities




    MS may produce bouts of coughing (confused with bronchitis)

    Hemoptysis from heart disease (rare)

    sputum usually white, but can be blood streaked (high pulmonary pressure from chronic

    CHF, MS, Eisenmenger’s, impinging aortic aneurysm)


    RAD (Asthma)

    cardiac wheezing - don’t forget about this – which responds to albuterol also

Cavitary lesion of lungs [characteristic wall pattern]



    Bacteria (thick): S. aureus, S pneumo (only type 3), Pseudomonas, klebsiella, legionella,

    H. influenza Tb (Gohn complex), M. avium, rhodococcus, actinomyces/nocardia,

    burkholderia, peptostreptococcus, prevotela, bacteroides, fusobacterium

    Parasites: entamoeba, toxoplasma, paragonimiasis, echinococcus (think lower lobe, R > L)

    Fungal: histoplasma (variable)

    blastomycosis, cryptococcus (thick)

    aspergillosis, coccidioides (thin)

    mucor, penicillum marneffei, PCP

    Developmental: sequestration (thick or thin), bronchial cyst (thin)

    Immunology: Wegener’s (thick, irregular), Goodpasteur’s (bilateral), rheumatoid, sarcoidosis


    Neoplasm: pulmonary (SCC) (thick, irregular), metastasis (adenoma or sarcoma) and Hodgkin’s

    lymphoma (thick or thin), adenoma, teratoma

    Vascular: septic thromboembolism (thick or thin, shaggy wall)

Inhaled: silicosis, coal worker’s (thick, irregular)

    Other: Blebs or bullae (when infected) / cystic bronchiectasis, pulmonary laceration

    Pleural Effusion (see lungs)

PE: dullness to percussion, hyporesonance, decreased fremitus (increased with pneumonia), large

    effusion may shift trachea to opposite side / not generally associated with pain

    Exudate criteria: protein > 3 (0.5 ratio) / LDH > 200 (0.6 ratio) Clues: RF or glucose < 20 ? RA / leukoerythrogenic cells (so-called LE cells) ? SLE / 2x

    amylase ? pancreatitis/ruptured esophagus / Hct > 20% ? hemothorax / increased lymphocytes

    ? Tb or malignancy



    Left and right heart failure (if unilateral, usually right-sided)

    Pulmonary venous hypertension with right heart failure

    Autoimmune phenomena after heart injury

    Postpericardotomy syndrome / Dressler’s syndrome (post-MI)


    Inflammation (pleura or lung)


    Malignancy (can get pain with mesothelioma)


    Collagen disease with pulmonary involvement: SLE, RA

    Trauma: hemothorax, chylothorax (thoracic duct), esophagus Abdominal

    Pancreatitis (left sided effusion)


    Abdominal ascites






    Nephrotic syndrome

    Drugs: nitrofurantoin, dantrolene, dopamine agonists, amiodarone, quinidine, IL-2

    Erythema Nodosum (see derm)

usually painful


    Post-Strep pharyngitis (ARF)

    Yersinia enteritis




    Atypical mycobacterial infection (M. lepra)

    Immunodeficiency-related infection


    Infectious mononucleosis


    Sarcoidosis (Lofgren’s)



    IBD (ulcerative colitis)

    Behçet’s (see below)


     oral contraceptives / sulfonamides, bromides, gold


    Female > male (5:1) mean age 31 yrs

    Acute phase reactant may be elevated without correlation to underlying disease

     Other (not exactly erythema nodosum)

     Behçet’s, superficial thrombophlebitis, cutaneous vasculitides

    Subcutaneous nodules

    Infections: a jillion

    Neoplasms: neuroblastoma

    Onchocerciasis (parasite)

    Nodules and Arthritis

    RA, SLE, gout, sarcoid, sporotrichosis, MRH, type II hyperlipidemia, palmer fasciitis, CrEST

    Splinter hemorrhages

    Endocarditis / rheumatoid arthritis / vasculitis?

Livedo Reticularis

    Atheroembolic syndrome


    Type II cryoglobulinemia

    APS (Snedden syndrome)


    ? See more on infectious exanthems

     Petechial Rashes

     Serious infections: Neisseria meningitides, RMSF, atypical measles

    Other: endocarditis, DIC


     Toxic shock syndrome, Kawasaki’s, scarlet fever, drug reactions

    Hand and Foot Rash

    Secondary syphilis

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