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Coronavirus differential diagnosis

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 infection should be differentiated from other diseases presenting with cough, fever, shortness of breath and tachypnea.

Differentiating Coronavirus Infection from other Diseases

Coronavirus infection 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]

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 –
  • Consolidation
  • Peripheral ground glass opacity
 βœ” βœ” βœ” βœ”/- βœ” βœ” – βœ”/- – –
  • Possible exposure to infected animals or persons
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)
 βœ” βœ” βœ” (Low grade) βœ” βœ” (In case of massive PE) βœ” – – – –
Congestive heart failure
  • Goldberg’s criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
    • SV1 or SV2 + RV5 or RV6 β‰₯3.5 mV
    • Total QRS amplitude in each of the limb leads ≀0.8 mV
    • R/S ratio <1 in lead V4
 βœ” βœ” βœ” – – βœ” – – – –
Percarditis
  • ST elevation
  • PR depression
  • Large collection of fluid inside the pericardial sac (pericardial effusion)
  • Calcification of pericardial sac
 βœ” βœ” βœ” (Low grade) βœ” (Relieved by sitting up and leaning forward) – βœ” – – – –
  • May be clinically classified into:
    • Acute (< 6 weeks)
    • Sub-acute (6 weeks – 6 months)
    • Chronic (> 6 months)
Pneumonia βœ” βœ” βœ” βœ” – βœ” βœ” – – –
Vasculitis

Homogeneous, circumferential vessel wall swelling

βœ” βœ” βœ” βœ” βœ” βœ” – βœ” βœ” βœ”
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
 βœ” βœ” – – – βœ” βœ” – – –


Differentiating 2019-nCoV, 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
2019-nCoV
  • 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, IFNΞ³, IP10, and MCP1
  • GCSF, IP10, MCP1, MIP1A, and TNFΞ± (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 trasnmission
  • Reservoirs:
    • Bats
    • Civets
    • Camels
  • 2494 confirmed cases
  • 858 deaths
  • Mortality rate of 34%
  • IFNΞ³, TNFΞ±, 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, IFNΞ³, IP10, and MCP1
  • On CT scan:
    • Airspace consolidation
    • Focal or multi-focal opacities

References

  1. ↑ Brenes-Salazar JA (2014). “Westermark’s and Palla’s signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era”. J Emerg Trauma Shock. 7 (1): 57–8. doi:10.4103/0974-2700.125645. PMCΒ 3912657. PMIDΒ 24550636.
  2. ↑ “CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics”.
  3. ↑ BΔ•lohlΓ‘vek J, Dytrych V, Linhart A (2013). “Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism”. Exp Clin Cardiol. 18 (2): 129–38. PMCΒ 3718593. PMIDΒ 23940438.
  4. ↑ “Pulmonary Embolism: Symptoms – National Library of Medicine – PubMed Health”.
  5. ↑ Ramani GV, Uber PA, Mehra MR (2010). “Chronic heart failure: contemporary diagnosis and management”. Mayo Clin. Proc. 85 (2): 180–95. doi:10.4065/mcp.2009.0494. PMCΒ 2813829. PMIDΒ 20118395.
  6. ↑ Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL (2008). “Symptom distress and quality of life in patients with advanced congestive heart failure”. J Pain Symptom Manage. 35 (6): 594–603. doi:10.1016/j.jpainsymman.2007.06.007. PMCΒ 2662445. PMIDΒ 18215495.
  7. ↑ Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ (2009). “Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology”. Eur. J. Heart Fail. 11 (2): 130–9. doi:10.1093/eurjhf/hfn013. PMCΒ 2639415. PMIDΒ 19168510.
  8. ↑ Takasugi JE, Godwin JD (1998). “Radiology of chronic obstructive pulmonary disease”. Radiol. Clin. North Am. 36 (1): 29–55. PMIDΒ 9465867.
  9. ↑ Wedzicha JA, Donaldson GC (2003). “Exacerbations of chronic obstructive pulmonary disease”. Respir Care. 48 (12): 1204–13, discussion 1213–5. PMIDΒ 14651761.
  10. ↑ Nakawah MO, Hawkins C, Barbandi F (2013). “Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome”. J Am Board Fam Med. 26 (4): 470–7. doi:10.3122/jabfm.2013.04.120256. PMIDΒ 23833163.
  11. ↑ Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (2010). “Pericardial disease: diagnosis and management”. Mayo Clin. Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMCΒ 2878263. PMIDΒ 20511488.
  12. ↑ Bogaert J, Francone M (2013). “Pericardial disease: value of CT and MR imaging”. Radiology. 267 (2): 340–56. doi:10.1148/radiol.13121059. PMIDΒ 23610095.
  13. ↑ Gharib AM, Stern EJ (2001). “Radiology of pneumonia”. Med. Clin. North Am. 85 (6): 1461–91, x. PMIDΒ 11680112.
  14. ↑ Schmidt WA (2013). “Imaging in vasculitis”. Best Pract Res Clin Rheumatol. 27 (1): 107–18. doi:10.1016/j.berh.2013.01.001. PMIDΒ 23507061.
  15. ↑ Suresh E (2006). “Diagnostic approach to patients with suspected vasculitis”. Postgrad Med J. 82 (970): 483–8. doi:10.1136/pgmj.2005.042648. PMCΒ 2585712. PMIDΒ 16891436.
  16. ↑ Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). “The electrocardiogram in acute pulmonary embolism”. Prog Cardiovasc Dis. 17 (4): 247–57. PMIDΒ 123074.
  17. ↑ Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML (2013). “Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease”. COPD. 10 (1): 62–71. doi:10.3109/15412555.2012.727918. PMIDΒ 23413894.
  18. ↑ Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H (2012). “Electrocardiogram in pneumonia”. Am. J. Cardiol. 110 (12): 1836–40. doi:10.1016/j.amjcard.2012.08.019. PMIDΒ 23000104.
  19. ↑ Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S (2015). “Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis”. Int. J. Cardiol. 199: 170–9. doi:10.1016/j.ijcard.2015.06.087. PMIDΒ 26209947.
  20. ↑ Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S (2010). “Cardiac involvement in Churg-Strauss syndrome”. Arthritis Rheum. 62 (2): 627–34. doi:10.1002/art.27263. PMIDΒ 20112390.
  21. ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/symptoms.html. Missing or empty |title= (help)
  22. ↑ Huang, Chaolin; Wang, Yeming; Li, Xingwang; Ren, Lili; Zhao, Jianping; Hu, Yi; Zhang, Li; Fan, Guohui; Xu, Jiuyang; Gu, Xiaoying; Cheng, Zhenshun; Yu, Ting; Xia, Jiaan; Wei, Yuan; Wu, Wenjuan; Xie, Xuelei; Yin, Wen; Li, Hui; Liu, Min; Xiao, Yan; Gao, Hong; Guo, Li; Xie, Jungang; Wang, Guangfa; Jiang, Rongmeng; Gao, Zhancheng; Jin, Qi; Wang, Jianwei; Cao, Bin (2020). “Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China”. The Lancet. doi:10.1016/S0140-6736(20)30183-5. ISSNΒ 0140-6736.
  23. ↑ Chan, Jasper Fuk-Woo; Kok, Kin-Hang; Zhu, Zheng; Chu, Hin; To, Kelvin Kai-Wang; Yuan, Shuofeng; Yuen, Kwok-Yung (2020). “Genomic characterization of the 2019 novel human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting Wuhan”. Emerging Microbes & Infections. 9 (1): 221–236. doi:10.1080/22221751.2020.1719902. ISSNΒ 2222-1751.
  24. ↑ Lu, Roujian; Zhao, Xiang; Li, Juan; Niu, Peihua; Yang, Bo; Wu, Honglong; Wang, Wenling; Song, Hao; Huang, Baoying; Zhu, Na; Bi, Yuhai; Ma, Xuejun; Zhan, Faxian; Wang, Liang; Hu, Tao; Zhou, Hong; Hu, Zhenhong; Zhou, Weimin; Zhao, Li; Chen, Jing; Meng, Yao; Wang, Ji; Lin, Yang; Yuan, Jianying; Xie, Zhihao; Ma, Jinmin; Liu, William J; Wang, Dayan; Xu, Wenbo; Holmes, Edward C; Gao, George F; Wu, Guizhen; Chen, Weijun; Shi, Weifeng; Tan, Wenjie (2020). “Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding”. The Lancet. doi:10.1016/S0140-6736(20)30251-8. ISSNΒ 0140-6736.
  25. ↑ Ajlan, Amr M.; Ahyad, Rayan A.; Jamjoom, Lamia Ghazi; Alharthy, Ahmed; Madani, Tariq A. (2014). “Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection: Chest CT Findings”. American Journal of Roentgenology. 203 (4): 782–787. doi:10.2214/AJR.14.13021. ISSNΒ 0361-803X.
  26. ↑ Huang, Chaolin; Wang, Yeming; Li, Xingwang; Ren, Lili; Zhao, Jianping; Hu, Yi; Zhang, Li; Fan, Guohui; Xu, Jiuyang; Gu, Xiaoying; Cheng, Zhenshun; Yu, Ting; Xia, Jiaan; Wei, Yuan; Wu, Wenjuan; Xie, Xuelei; Yin, Wen; Li, Hui; Liu, Min; Xiao, Yan; Gao, Hong; Guo, Li; Xie, Jungang; Wang, Guangfa; Jiang, Rongmeng; Gao, Zhancheng; Jin, Qi; Wang, Jianwei; Cao, Bin (2020). “Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China”. The Lancet. doi:10.1016/S0140-6736(20)30183-5. ISSNΒ 0140-6736.
  27. ↑ “Coronavirus | Home | CDC”.
  28. ↑ Nassar MS, Bakhrebah MA, Meo SA, Alsuabeyl MS, Zaher WA (August 2018). “Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection: epidemiology, pathogenesis and clinical characteristics”. Eur Rev Med Pharmacol Sci. 22 (15): 4956–4961. doi:10.26355/eurrev_201808_15635. PMIDΒ 30070331.
  29. ↑ Xia S, Liu Q, Wang Q, Sun Z, Su S, Du L, Ying T, Lu L, Jiang S (December 2014). “Middle East respiratory syndrome coronavirus (MERS-CoV) entry inhibitors targeting spike protein”. Virus Res. 194: 200–10. doi:10.1016/j.virusres.2014.10.007. PMIDΒ 25451066.
  30. ↑ Hajjar SA, Memish ZA, McIntosh K (2013). “Middle East Respiratory Syndrome Coronavirus (MERS-CoV): a perpetual challenge”. Ann Saudi Med. 33 (5): 427–36. doi:10.5144/0256-4947.2013.427. PMCΒ 6074883. PMIDΒ 24188935.
  31. ↑ Memish ZA, Assiri AM, Al-Tawfiq JA (December 2014). “Middle East respiratory syndrome coronavirus (MERS-CoV) viral shedding in the respiratory tract: an observational analysis with infection control implications”. Int. J. Infect. Dis. 29: 307–8. doi:10.1016/j.ijid.2014.10.002. PMIDΒ 25448335.
  32. ↑ Satija N, Lal SK (April 2007). “The molecular biology of SARS coronavirus”. Ann. N. Y. Acad. Sci. 1102: 26–38. doi:10.1196/annals.1408.002. PMIDΒ 17470909.
  33. ↑ Bolles M, Donaldson E, Baric R (December 2011). “SARS-CoV and emergent coronaviruses: viral determinants of interspecies transmission”. Curr Opin Virol. 1 (6): 624–34. doi:10.1016/j.coviro.2011.10.012. PMCΒ 3237677. PMIDΒ 22180768.
  34. ↑ Fehr AR, Perlman S (2015). “Coronaviruses: an overview of their replication and pathogenesis”. Methods Mol. Biol. 1282: 1–23. doi:10.1007/978-1-4939-2438-7_1. PMCΒ 4369385. PMIDΒ 25720466.

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