Non-bacterial thrombotic endocarditis differential diagnosis: Difference between revisions

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Latest revision as of 19:11, 6 August 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2]

Overview

Non-bacterial thrombotic endocarditis must be differentiated from other diseases that cause a new or changed heart murmur, multiple systemic emboli, +/-fever, such as infective endocarditis, degenerative valvular disease, and pulmonary infarction.

Differential Diagnosis

Non-bacterial thrombotic endocarditis must be differentiated from other diseases that cause a new or changed heart murmur, multiple systemic emboli, +/-fever, such as;^[1]^[2]^[3]^[4]^[5]^[6].

Diseases	CT scan and MRI	EKG	Chest X-ray	Tachypnea	Tachycardia	Fever	Chest Pain	Hemoptysis	Dyspnea on Exertion	Wheezing	Chest Tenderness	Nasalopharyngeal Ulceration	Carotid Bruit	Past medical history	Other Findings
Diseases	Diagnostic tests			Physical Examination			Symptoms							Past medical history	Other Findings
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
Infective Endocarditis		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		✔	✔	✔	-	-	✔	-	-	-	-	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
Non-bacterial thrombotic endocarditis		ST elevation PR depression		✔	✔	✔ (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)
Libman Sack Endocarditis		Prolonged PR interval Transient T wave inversions		✔	✔	✔	✔	-	✔	✔	-	-	-	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
Fever of unknown origin (FUO)		Multifocal atrial tachycardia (atleast 3 distinct P wave morphologies)		✔	✔	-	-	-	✔	✔	-	-	-	Smoking Alpha-1 antitrypsin deficiency Increased sputum production (chronic bronchitis) Cough	Alpha 1 antitrypsin deficiency may be associated with hepatomegaly

Differentiating [Disease name] from other Diseases

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].

OR

As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].

References

↑ "Libman-Sacks Endocarditis Differential Diagnoses".
↑ "Nonbacterial Thrombotic Endocarditis: Clinicopathologic Study of a Necropsy Series | Revista Española de Cardiología (English Edition)".
↑ Lopez JA, Ross RS, Fishbein MC, Siegel RJ (March 1987). "Nonbacterial thrombotic endocarditis: a review". Am. Heart J. 113 (3): 773–84. doi:10.1016/0002-8703(87)90719-8. PMID 3548296.
↑ Borowski A, Ghodsizad A, Cohnen M, Gams E (June 2005). "Recurrent embolism in the course of marantic endocarditis". Ann. Thorac. Surg. 79 (6): 2145–7. doi:10.1016/j.athoracsur.2003.12.024. PMID 15919332.
↑ Aryana A, Esterbrooks DJ, Morris PC (December 2006). "Nonbacterial thrombotic endocarditis with recurrent embolic events as manifestation of ovarian neoplasm". J Gen Intern Med. 21 (12): C12–5. doi:10.1111/j.1525-1497.2006.00614.x. PMC 1924740. PMID 16965557.
↑ Singhal AB, Topcuoglu MA, Buonanno FS (May 2002). "Acute ischemic stroke patterns in infective and nonbacterial thrombotic endocarditis: a diffusion-weighted magnetic resonance imaging study". Stroke. 33 (5): 1267–73. doi:10.1161/01.str.0000015029.91577.36. PMID 11988602.

Template:WH Template:WS

[urlLibman-Sacks_Endocarditis_Differential_Diagnoses-1] "Libman-Sacks Endocarditis Differential Diagnoses".

[urlNonbacterial_Thrombotic_Endocarditis:_Clinicopathologic_Study_of_a_Necropsy_Series_|_Revista_Española_de_Cardiología_(English_Edition)-2] "Nonbacterial Thrombotic Endocarditis: Clinicopathologic Study of a Necropsy Series | Revista Española de Cardiología (English Edition)".

[pmid3548296-3] Lopez JA, Ross RS, Fishbein MC, Siegel RJ (March 1987). "Nonbacterial thrombotic endocarditis: a review". Am. Heart J. 113 (3): 773–84. doi:10.1016/0002-8703(87)90719-8. PMID 3548296.

[pmid15919332-4] Borowski A, Ghodsizad A, Cohnen M, Gams E (June 2005). "Recurrent embolism in the course of marantic endocarditis". Ann. Thorac. Surg. 79 (6): 2145–7. doi:10.1016/j.athoracsur.2003.12.024. PMID 15919332.

[pmid16965557-5] Aryana A, Esterbrooks DJ, Morris PC (December 2006). "Nonbacterial thrombotic endocarditis with recurrent embolic events as manifestation of ovarian neoplasm". J Gen Intern Med. 21 (12): C12–5. doi:10.1111/j.1525-1497.2006.00614.x. PMC 1924740. PMID 16965557.

[pmid11988602-6] Singhal AB, Topcuoglu MA, Buonanno FS (May 2002). "Acute ischemic stroke patterns in infective and nonbacterial thrombotic endocarditis: a diffusion-weighted magnetic resonance imaging study". Stroke. 33 (5): 1267–73. doi:10.1161/01.str.0000015029.91577.36. PMID 11988602.

[1]

[2]

[3]

[4]

[5]

[6]

@@ Line 3: / Line 3: @@
 {{non-bacterial thrombotic endocarditis}}
-{{CMG}}; {{AE}}{{Homa}}
+{{CMG}}; {{AE}}{{Aisha}}
 ==Overview==
-[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
+[[Non-bacterial thrombotic endocarditis]] must be differentiated from other [[diseases]] that cause a new or changed [[heart murmur]], multiple [[Systemic embolization|systemic emboli]], +/-[[fever]], such as [[infective endocarditis]], [[Valvular Diseases|degenerative valvular disease]], and [[Pulmonary embolism|pulmonary infarction]].
-OR
+==Differential Diagnosis==
+[[Non-bacterial thrombotic endocarditis]] must be differentiated from other [[diseases]] that cause a new or changed [[heart murmur]], multiple [[Systemic embolization|systemic emboli]], +/-[[fever]], such as;<ref name="urlLibman-Sacks Endocarditis Differential Diagnoses">{{cite web |url=https://emedicine.medscape.com/article/155230-differential |title=Libman-Sacks Endocarditis Differential Diagnoses |format= |work= |accessdate=}}</ref><ref name="urlNonbacterial Thrombotic Endocarditis: Clinicopathologic Study of a Necropsy Series | Revista Española de Cardiología (English Edition)">{{cite web |url=https://www.revespcardiol.org/en-nonbacterial-thrombotic-endocarditis-clinicopathologic-study-articulo-13106392 |title=Nonbacterial Thrombotic Endocarditis: Clinicopathologic Study of a Necropsy Series &#124; Revista Española de Cardiología (English Edition) |format= |work= |accessdate=}}</ref><ref name="pmid3548296">{{cite journal |vauthors=Lopez JA, Ross RS, Fishbein MC, Siegel RJ |title=Nonbacterial thrombotic endocarditis: a review |journal=Am. Heart J. |volume=113 |issue=3 |pages=773–84 |date=March 1987 |pmid=3548296 |doi=10.1016/0002-8703(87)90719-8 |url=}}</ref><ref name="pmid15919332">{{cite journal |vauthors=Borowski A, Ghodsizad A, Cohnen M, Gams E |title=Recurrent embolism in the course of marantic endocarditis |journal=Ann. Thorac. Surg. |volume=79 |issue=6 |pages=2145–7 |date=June 2005 |pmid=15919332 |doi=10.1016/j.athoracsur.2003.12.024 |url=}}</ref><ref name="pmid16965557">{{cite journal |vauthors=Aryana A, Esterbrooks DJ, Morris PC |title=Nonbacterial thrombotic endocarditis with recurrent embolic events as manifestation of ovarian neoplasm |journal=J Gen Intern Med |volume=21 |issue=12 |pages=C12–5 |date=December 2006 |pmid=16965557 |pmc=1924740 |doi=10.1111/j.1525-1497.2006.00614.x |url=}}</ref><ref name="pmid11988602">{{cite journal |vauthors=Singhal AB, Topcuoglu MA, Buonanno FS |title=Acute ischemic stroke patterns in infective and nonbacterial thrombotic endocarditis: a diffusion-weighted magnetic resonance imaging study |journal=Stroke |volume=33 |issue=5 |pages=1267–73 |date=May 2002 |pmid=11988602 |doi=10.1161/01.str.0000015029.91577.36 |url=}}</ref>.
-[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
+*[[Infective endocarditis]],
+*[[Valvular Diseases|Degenerative valvular disease]], and
-==Differentiating [Disease name] from other Diseases==
+*[[Pulmonary embolism|Pulmonary infarction]].
-[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
-OR
-[Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].
-OR
-As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].
-===Differentiating [disease name] from other diseases on the basis of [symptom 1], [symptom 2], and [symptom 3]===
-The differentials include the following:<ref name="pmid24550636">{{cite journal |vauthors=Brenes-Salazar JA |title=Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era |journal=J Emerg Trauma Shock |volume=7 |issue=1 |pages=57–8 |year=2014 |pmid=24550636 |pmc=3912657 |doi=10.4103/0974-2700.125645 |url=}}</ref><ref name="urlCT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics">{{cite web |url=http://pubs.rsna.org/doi/full/10.1148/rg.245045008 |title=CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis &#124; RadioGraphics |format= |work= |accessdate=}}</ref><ref name="pmid23940438">{{cite journal |vauthors=Bĕlohlávek J, Dytrych V, Linhart A |title=Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism |journal=Exp Clin Cardiol |volume=18 |issue=2 |pages=129–38 |year=2013 |pmid=23940438 |pmc=3718593 |doi= |url=}}</ref><ref name="urlPulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022657/ |title=Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health |format= |work= |accessdate=}}</ref><ref name="pmid20118395">{{cite journal |vauthors=Ramani GV, Uber PA, Mehra MR |title=Chronic heart failure: contemporary diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=2 |pages=180–95 |year=2010 |pmid=20118395 |pmc=2813829 |doi=10.4065/mcp.2009.0494 |url=}}</ref><ref name="pmid18215495">{{cite journal |vauthors=Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL |title=Symptom distress and quality of life in patients with advanced congestive heart failure |journal=J Pain Symptom Manage |volume=35 |issue=6 |pages=594–603 |year=2008 |pmid=18215495 |pmc=2662445 |doi=10.1016/j.jpainsymman.2007.06.007 |url=}}</ref><ref name="pmid19168510">{{cite journal |vauthors=Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ |title=Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology |journal=Eur. J. Heart Fail. |volume=11 |issue=2 |pages=130–9 |year=2009 |pmid=19168510 |pmc=2639415 |doi=10.1093/eurjhf/hfn013 |url=}}</ref><ref name="pmid9465867">{{cite journal |vauthors=Takasugi JE, Godwin JD |title=Radiology of chronic obstructive pulmonary disease |journal=Radiol. Clin. North Am. |volume=36 |issue=1 |pages=29–55 |year=1998 |pmid=9465867 |doi= |url=}}</ref><ref name="pmid14651761">{{cite journal |vauthors=Wedzicha JA, Donaldson GC |title=Exacerbations of chronic obstructive pulmonary disease |journal=Respir Care |volume=48 |issue=12 |pages=1204–13; discussion 1213–5 |year=2003 |pmid=14651761 |doi= |url=}}</ref><ref name="pmid23833163">{{cite journal |vauthors=Nakawah MO, Hawkins C, Barbandi F |title=Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome |journal=J Am Board Fam Med |volume=26 |issue=4 |pages=470–7 |year=2013 |pmid=23833163 |doi=10.3122/jabfm.2013.04.120256 |url=}}</ref><ref name="pmid20511488">{{cite journal |vauthors=Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK |title=Pericardial disease: diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=6 |pages=572–93 |year=2010 |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref><ref name="pmid23610095">{{cite journal |vauthors=Bogaert J, Francone M |title=Pericardial disease: value of CT and MR imaging |journal=Radiology |volume=267 |issue=2 |pages=340–56 |year=2013 |pmid=23610095 |doi=10.1148/radiol.13121059 |url=}}</ref><ref name="pmid11680112">{{cite journal |vauthors=Gharib AM, Stern EJ |title=Radiology of pneumonia |journal=Med. Clin. North Am. |volume=85 |issue=6 |pages=1461–91, x |year=2001 |pmid=11680112 |doi= |url=}}</ref><ref name="pmid23507061">{{cite journal |vauthors=Schmidt WA |title=Imaging in vasculitis |journal=Best Pract Res Clin Rheumatol |volume=27 |issue=1 |pages=107–18 |year=2013 |pmid=23507061 |doi=10.1016/j.berh.2013.01.001 |url=}}</ref><ref name="pmid16891436">{{cite journal |vauthors=Suresh E |title=Diagnostic approach to patients with suspected vasculitis |journal=Postgrad Med J |volume=82 |issue=970 |pages=483–8 |year=2006 |pmid=16891436 |pmc=2585712 |doi=10.1136/pgmj.2005.042648 |url=}}</ref><ref name="pmid123074">{{cite journal |vauthors=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW |title=The electrocardiogram in acute pulmonary embolism |journal=Prog Cardiovasc Dis |volume=17 |issue=4 |pages=247–57 |year=1975 |pmid=123074 |doi= |url=}}</ref><ref name="pmid23413894">{{cite journal |vauthors=Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML |title=Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease |journal=COPD |volume=10 |issue=1 |pages=62–71 |year=2013 |pmid=23413894 |doi=10.3109/15412555.2012.727918 |url=}}</ref><ref name="pmid23000104">{{cite journal |vauthors=Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H |title=Electrocardiogram in pneumonia |journal=Am. J. Cardiol. |volume=110 |issue=12 |pages=1836–40 |year=2012 |pmid=23000104 |doi=10.1016/j.amjcard.2012.08.019 |url=}}</ref><ref name="pmid26209947">{{cite journal |vauthors=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 |title=Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis |journal=Int. J. Cardiol. |volume=199 |issue= |pages=170–9 |year=2015 |pmid=26209947 |doi=10.1016/j.ijcard.2015.06.087 |url=}}</ref><ref name="pmid20112390">{{cite journal |vauthors=Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S |title=Cardiac involvement in Churg-Strauss syndrome |journal=Arthritis Rheum. |volume=62 |issue=2 |pages=627–34 |year=2010 |pmid=20112390 |doi=10.1002/art.27263 |url=}}</ref><small>
+<small>
 {|
 |- style="background: #4479BA; color: #FFFFFF; text-align: center;"
@@ Line 35: / Line 23: @@
 ! rowspan="2" |<small>Other Findings</small>
 |- style="background: #4479BA; color: #FFFFFF; text-align: center;"
 !<small>CT scan and MRI</small>
 !<small>EKG</small>
 !<small>Chest X-ray</small>
 !<small>Tachypnea</small>
 !<small>Tachycardia</small>
@@ Line 50: / Line 38: @@
 |-
 | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pulmonary embolism]]
-| style="background: #F5F5F5; padding: 5px;" |
+| style="background: #F5F5F5; padding: 5px; text-align:center" |
-*On [[CT angiography]]:
+* On [[CT angiography]]:
 ** Intra-luminal filling defect
 *On [[MRI]]:
 ** Narrowing of involved [[Blood vessel|vessel]]
@@ Line 58: / Line 46: @@
 ** Polo-mint sign (partial filling defect surrounded by contrast)
 | style="background: #F5F5F5; padding: 5px;" |
-*[[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain
+* [[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain
 | style="background: #F5F5F5; padding: 5px;" |
-*[[Fleischner sign]] (enlarged pulmonary artery), [[Hampton's hump|Hampton hump]], [[Westermark's sign]]
+* [[Fleischner sign]] (enlarged pulmonary artery), [[Hampton's hump|Hampton hump]], [[Westermark's sign]]
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
@@ Line 67: / Line 55: @@
 | style="background: #F5F5F5; padding: 5px;" |✔ (In case of massive PE)
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |
 *Hypercoagulating conditions ([[Factor V Leiden]], [[thrombophilia]], [[deep vein thrombosis]], immobilization, [[malignancy]], [[pregnancy]])
@@ Line 76: / Line 64: @@
 * May be associated with [[metabolic alkalosis]] and [[syncope]]
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Congestive heart failure]]
+| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Infective Endocarditis]]
 | style="background: #F5F5F5; padding: 5px;" |
-*On [[Computed tomography|CT scan]]:
-**[[Mediastinal lymphadenopathy]]
-** Hazy [[mediastinal]] fat
-*On [[Magnetic resonance imaging|MRI]]:
-** Abnormality of [[cardiac]] chambers ([[Hypertrophy (medical)|hypertrophy]], dilation)
-** Delayed enhancement [[MRI]] may help characterize the [[myocardial]] [[Tissue (biology)|tissue]] ([[fibrosis]])
-** Late enhancement of contrast in conditions such as [[myocarditis]], [[sarcoidosis]], [[amyloidosis]], [[Anderson-Fabry disease|Anderson-Fabry]]'s disease, [[Chagas disease]])
 | style="background: #F5F5F5; padding: 5px;" |
 *Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
 **[[S wave|S]]V1 or [[S wave|S]]V2 + [[R wave|R]]V5 or [[R wave|R]]V6 ≥3.5 mV
 **Total [[QRS complex|QRS]] amplitude in each of the limb leads ≤0.8 mV
-**[[R wave|R]]/[[S wave|S]] ratio <1 in lead V4
+** [[R wave|R]]/[[S wave|S]] ratio <1 in lead V4
 | style="background: #F5F5F5; padding: 5px;" |
-*[[Cardiomegaly]]
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |
 *Previous [[myocardial infarction]]
@@ Line 110: / Line 90: @@
 | style="background: #F5F5F5; padding: 5px;" |
 *[[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]]
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Percarditis]]
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Non-bacterial thrombotic endocarditis|Non-bacterial thrombotic endocarditis]]
 | style="background: #F5F5F5; padding: 5px;" |
-*On contrast enhanced [[Computed tomography|CT scan]]:
-**Enhancement of the [[pericardium]] (due to [[inflammation]])
-**[[Pericardial effusion]]
-**[[Pericardial calcification]]
-*On [[gadolinium]]-enhanced fat-saturated [[Magnetic resonance imaging|T1-weighted MRI]]:
-**[[Pericardial]] enhancement (due to [[inflammation]])
-**[[Pericardial effusion]]
 | style="background: #F5F5F5; padding: 5px;" |
 *ST elevation
 *PR depression
 | style="background: #F5F5F5; padding: 5px;" |
-*Large collection of fluid inside the pericardial sac (pericardial effusion)
-*Calcification of pericardial sac
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔ (Low grade)
 | style="background: #F5F5F5; padding: 5px;" |✔ (Relieved by sitting up and leaning forward)
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |
 *Infections:
@@ Line 159: / Line 130: @@
 **Chronic (> 6 months)
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumonia]]
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Libman Sack Endocarditis]]
 | style="background: #F5F5F5; padding: 5px;" |
-*On [[Computed tomography|CT scan]]: (not generally indicated)
-**[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar pneumonia)
-**Peribronchial [[nodules]] ([[bronchopneumonia]])
-**[[Ground glass opacification on CT|Ground-glass opacity]] (GGO)
-**[[Abscess]]
-**[[Pleural effusion]]
-**On [[MRI]]:
-*Not indicated
 | style="background: #F5F5F5; padding: 5px;" |
 *Prolonged [[PR interval]]
 *Transient [[T wave]] inversions
 | style="background: #F5F5F5; padding: 5px;" |
-*[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar [[pneumonia]])
-*Peribronchial [[nodules]] (bronchopneumonia)
-*Ground-glass opacity (GGO)
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |
 *Ill-contact
@@ Line 204: / Line 164: @@
 **Masses or nodules ([[Anti-neutrophil cytoplasmic antibody|ANCA]]-associated granulomatous vasculitis)
 *On [[Magnetic resonance imaging|MRI]]:
+Homogeneous, circumferential [[Blood vessel|vessel]] wall [[swelling]]
-Homogeneous, circumferential [[Blood vessel|vessel]] wall [[swelling]]
 | style="background: #F5F5F5; padding: 5px;" |
 *[[Bundle branch block|Right or left bundle-branch block]] ([[Churg-Strauss syndrome]])
 *[[Atrial fibrillation]] ([[Churg-Strauss syndrome]])
 *Non-specific [[ST interval|ST segment]] and [[T wave]] changes
 | style="background: #F5F5F5; padding: 5px;" |
 *[[Nodule (medicine)|Nodules]]
@@ Line 219: / Line 178: @@
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
@@ Line 230: / Line 189: @@
 | style="background: #F5F5F5; padding: 5px;" |
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic obstructive pulmonary disease]] (COPD)
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Fever of unknown origin]] (FUO)
 | style="background: #F5F5F5; padding: 5px;" |
-*On [[Computed tomography|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
 | style="background: #F5F5F5; padding: 5px;" |
 *[[Multifocal atrial tachycardia]] (atleast 3 distinct [[P waves|P wave]] morphologies)
 | style="background: #F5F5F5; padding: 5px;" |
-*Enlarged [[lung]] shadows ([[emphysema]])
-*Flattening of [[diaphragm]] ([[emphysema]])
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
-| style="background: #F5F5F5; padding: 5px;" |  -
+| style="background: #F5F5F5; padding: 5px;" | -
 | style="background: #F5F5F5; padding: 5px;" |
 *[[Smoking]]
@@ Line 264: / Line 212: @@
 *[[Alpha 1-antitrypsin deficiency|Alpha 1 antitrypsin deficiency]] may be associated with [[hepatomegaly]]
 |}
+==Differentiating [Disease name] from other Diseases==
+[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
+OR
+[Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].
+OR
+As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].
-On the basis [symptom 1], [symptom 2], and [symptom 3], [disease name] must be differentiated from [disease 1], [disease 2], [disease 3], [disease 4], [disease 5], and [disease 6].
-{|
-|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
-! rowspan="4"  style="background: #4479BA; color: #FFFFFF; text-align: center;|Diseases
-| colspan="6" rowspan="1"  style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Clinical manifestations'''
-! colspan="7" rowspan="2"  style="background: #4479BA; color: #FFFFFF; text-align: center;|Para-clinical findings
-| colspan="1" rowspan="4"  style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Gold standard'''
-! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;|Additional findings
-|-
-| colspan="3" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Symptoms'''
-! colspan="3" rowspan="2"  style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical examination
-|-
-! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab Findings
-! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging
-! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|Histopathology
-|-
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 1
-! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 2
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 3
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 1
-! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 2
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 3
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 1
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 2
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 3
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 1
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 2
-! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 3
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 1
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 2
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 3
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
-!Diseases
-!Symptom 1
-! colspan="1" rowspan="1" |Symptom 2
-!Symptom 3
-!Physical exam 1
-! colspan="1" rowspan="1" |Physical exam 2
-!Physical exam 3
-!Lab 1
-!Lab 2
-!Lab 3
-!Imaging 1
-!Imaging 2
-!Imaging 3
-!Histopathology
-|'''Gold standard'''
-!Additional findings
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 4
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 5
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 6
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |
-|}
 ==References==