COVID-19 differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Sabawoon Mirwais, M.B.B.S, M.D.[2];Syed Hassan A. Kazmi BSc, MD [3]

Overview

Coronavirus disease 2019 (COVID-19) should be differentiated from other diseases presenting with cough, fever, shortness of breath, and tachypnea.

Differentiating COVID-19 from other Diseases

Coronavirus disease 2019 (COVID-19) should be differentiated from other diseases presenting with cough, fever, 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][21][22][23][24][25][26][27][28]

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
COVID-19
  • Chest CT findings include:
    • Bilateral ground-glass opacities
    • Crazy paving sign
    • Air space consolidation
    • Traction bronchiectasis
    • Vascular enlargement of the lesion
-
  • Consolidation
  • Peripheral ground glass opacity
✔/- - ✔/- - -
  • Possible exposure to infected animals or persons
Influenza
  • Unilateral/bilateral ground glass opacities on chest CT
  • T wave flattening in the aVF and T wave inversion in lead III
  • ST-segment elevation in leads V1-V3 and ST-segment depression in the inferolateral lead distribution
  • Consolidation
✔/- ✔/- ✔/- - - - - ✔/- -
  • No history of flu vaccine
  • Exposure to individuals with same signs and symptoms
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)
✔ (Low grade) ✔ (In case of massive PE) - - - -
Congestive heart failure
  • 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
- - - - - -
Percarditis
  • 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) - - - - -
  • May be clinically classified into:
    • Acute (< 6 weeks)
    • Sub-acute (6 weeks - 6 months)
    • Chronic (> 6 months)
Pneumonia - - - -
Vasculitis

Homogeneous, circumferential vessel wall swelling

-
Chronic obstructive pulmonary disease (COPD)
  • On CT scan:
  • 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
- - - - - -


Differentiating SARS-CoV-2, MERS-CoV and SARS-CoV




Type of Coronavirus Origins Family (Lineage) Receptor Incubation Period Genome size Clinical Features Transmission Epidemiology Cytokine Profile Imaging Findings Serological Testing
Fever Dry cough Dyspnea Rhinorrhea Sneezing Sore throat Diarrhea
SARS-CoV-2
  • Huanan seafood market, Wuhan, Hubei China (December 2019)
  • Betacoronaviridea, subgenus: Sarbecovirus (Lineage B)
  • ACE1/2
  • 1-14 days
  • 29.8 kB (> 80% nucleotide identity with SARS-CoV)
++ ++ ++ + + + -
  • Human to human transmission through close contact
  • 14380 confirmed cases
  • 17 deaths
  • Males > females
  • Mortality rate 2.7%
  • IL1B, IFNγ, IP10, and MCP1
  • GCSF, IP10, MCP1, MIP1A, and TNFα (ICU-admitted)
  • IL4 and IL10
  • On CT scan:
    • Bilateral ground-glass opacities
    • Peripheral localization and subpleural sparing
MERS-CoV
  • Saudi Arabia (September 2012)
  • Betacoronaviridea (Lineage C)
  • DPP4 (CD26)
  • 2-14 days
  • 29.9 kB
++ ++ ++ ++ ++ ++ +
  • Limited human to human transmission
  • Reservoirs:
    • Bats
    • Civets
    • Camels
  • 2494 confirmed cases
  • 858 deaths
  • Mortality rate of 34%
  • IFNγ, TNFα, IL15, and IL17
  • On CT scan:
    • Bilateral, subpleural and basilar infiltrates
    • Ground glass opacities
    • Organizing pneumonia-like pattern (subpleural and peribroncho-vascular)
SARS-CoV
  • Guangdong, Southern China (November 2002)
  • Betacoronaviridea (Lineage B)
  • ACE2
  • 2-7 days
  • 29.3 kB
++ ++ ++ ++ ++ ++ +
  • Human to human transmission through close contact
  • Reservoirs:
    • Bats
    • Civets
    • Camels
  • 8098 cases
  • 774 deaths
  • Mortality rate of about 10%
  • IL1B, IL6, IL12, IFNγ, IP10, and MCP1
  • On CT scan:
    • Airspace consolidation
    • Focal or multi-focal opacities

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