Deep vein thrombosis differential diagnosis

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet

Overview

Deep vein thrombosis DVT is characterized by pain and swelling of the limb, which are not specific symptoms. There are other conditions that can mimic DVT such as muscle strain or muscle tear, immobilization that led to leg swelling, lymphedema, lymphangitis, chronic venous insufficiency, or cellulitis.

Differential Diagnosis

Deep vein thrombosis must be differentiated from other causes of lower limb edema like chronic venous insufficiency, lymphatic filariasis, lipedema, myxedema, cellulitis and causes of generalized edema.

Diseases	Symptoms							Signs	Gold standard Investigation to diagnose
Diseases	History	Onset	Pain	Fever	Laterality	Scrotal swelling	Symptoms of primary disease	Signs	Gold standard Investigation to diagnose
Acute deep venous thrombosis	History of prolonged recumbency Classic symptoms of DVT include acute unilateral swelling, pain, and erythema	Acute	+	–	Unilateral	–	May be associated with primary disease mandates recumbency for long duration	Dilated superficial veins Difference in calf diameter is twice as likely to have DVT(most impotant sign )^[1] Calf pain on passive dorsiflexion of the foot (Homan’s sign) isn’t realiable sign.	Compression ultrasonography (CUS) with doppler is the diagnostic test of choice D-dimer level is used for unprobable cases
Lymphatic filariasis	History of living in endemic area or travelling to it	Chronic	+	+	Bilateral	+	–	Hepatomegaly Lymphedema Elephantiasis Lymphangitis Hydrocele Scrotal elephantiasis Lymphadenopathies Rhonchi may be present in patients with Pulmonary tropical eosinophilia syndrome.	Preparing blood smears Thick smears Thick smears consist of a thick layer of dehemoglobinized (lysed) red blood cells (RBCs). Thick smears allow a more efficient detection of parasites (increased sensitivity). Thin smears consist of blood spread in a layer such that the thickness decrease. By the ultrasound, the following findings can be observed: Dilated lymphatic channels Living worms tend to be in motion which called “filarial dance” sign.
Chronic venous insufficiency	History of untreated varicose veins Painful bilateral lower limb swelling that increases with standing and decreases by rest and leg elevation.	Chronic	+	–	Bilateral	+ (If congenial)	–	Typical varicose veins Skin change distribution correlate with varicose veins sites in the medial side of ankle and leg Reduction of swelling with limb elevation.	Duplex ultrasound will demonstrate typical findings of venous valvular insufficiency
Lipedema	Family history especially in women; X-linked dominant or autosomal dominant condition.^[2] Abnormal deposition of fat and edema and easy bruising.	Chronic	+	–	Bilateral	–	–	Tender with palpation Negative Semmer sign to differentiate from lymphedema.^[3] Pinching the skin on the upper surface of the toes. If it is possible to grasp a thin fold of tissue then it is negative result. In a positive result, it is only possible to grasp a lump of tissue.	MRI offers strong qualitative and quantitative parameters in the diagnosis of lipedema ^[4]
Myxedema	History of untreated hypothyroidism. Infiltration of the skin with glycosaminoglycans with associated water retention.	Chronic	+	–	Bilateral	–	+ (hypothyroidism )	Pretibial myxedema	Thyroid function tests.
(Cellulitis–erysipelas-skin abscess)	Acute painful swelling Fever	Acute	+	+	Unilateral	–	–	Tenderness, hotness, and may be fluctuation if abscess formed. Lymphangitis in nearby lymph nodes. Toxemia and fever in severe cases. Cellulitis involves the deeper dermis and erysipelas involves the upper dermis.^[5]	Usually it doesn’t need any laboratory tests to diagnose.^[6] Blood cultures are warranted for patients in the following circumstances:^[7] Systemic toxicity Extensive skin or soft tissue involvement Underlying comorbidities persistent cellulitis In patients with recurrent cellulitis, serologic testing for beta-hemolytic streptococci is a good diagnostic tool.^[8]
Other causes of generalized edema	History of chronic general condition (cardiac-liver-renal)	Chronic	–	–	Bilateral	–	+		According to the primary cause ( Echo- LFTs– RFT)

Shown below is a list of conditions that can mimic DVT.

Venous
- Superficial thrombophlebitis
- Post-thrombotic syndrome
- Chronic venous insufficiency
- Venous obstruction

Other
- Cellulitis
- Torn gastrocnemius muscle
- Fracture
- Hematoma
- Acute arterial ischaemia
- Lymphoedema
- Hypoproteinemia (for example, cirrhosis, nephrotic syndrome)
- Muscle tear or leg strain
- Leg swelling in a paralyzed limb
- Lymphangitis or lymph obstruction
- Popliteal/Baker’s cyst
- Cellulitis
- Knee abnormality

References

↑ Goodacre S, Sutton AJ, Sampson FC (2005). “Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis”. Ann Intern Med. 143 (2): 129–39. PMID 16027455. Review in: ACP J Club. 2006 Mar-Apr;144(2):46-7 Review in: Evid Based Med. 2006 Apr;11(2):56
↑ Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S; et al. (2010). “Lipedema: an inherited condition”. Am J Med Genet A. 152A (4): 970–6. doi:10.1002/ajmg.a.33313. PMID 20358611.
↑ Trayes KP, Studdiford JS, Pickle S, Tully AS (2013). “Edema: diagnosis and management”. Am Fam Physician. 88 (2): 102–10. PMID 23939641.
↑ Dimakakos PB, Stefanopoulos T, Antoniades P, Antoniou A, Gouliamos A, Rizos D (1997). “MRI and ultrasonographic findings in the investigation of lymphedema and lipedema”. Int Surg. 82 (4): 411–6. PMID 9412843.
↑ Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). “Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America”. Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
↑ Raff AB, Kroshinsky D (2016). “Cellulitis: A Review”. JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.
↑ Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY (2000). “Cellulitis complicating lymphoedema”. Eur J Clin Microbiol Infect Dis. 19 (4): 294–7. PMID 10834819.
↑ Leppard BJ, Seal DV, Colman G, Hallas G (1985). “The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas”. Br J Dermatol. 112 (5): 559–67. PMID 4005155.

[pmid16027455-1] Goodacre S, Sutton AJ, Sampson FC (2005). “Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis”. Ann Intern Med. 143 (2): 129–39. PMID 16027455. Review in: ACP J Club. 2006 Mar-Apr;144(2):46-7 Review in: Evid Based Med. 2006 Apr;11(2):56

[pmid20358611-2] Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S; et al. (2010). “Lipedema: an inherited condition”. Am J Med Genet A. 152A (4): 970–6. doi:10.1002/ajmg.a.33313. PMID 20358611.

[pmid23939641-3] Trayes KP, Studdiford JS, Pickle S, Tully AS (2013). “Edema: diagnosis and management”. Am Fam Physician. 88 (2): 102–10. PMID 23939641.

[pmid9412843-4] Dimakakos PB, Stefanopoulos T, Antoniades P, Antoniou A, Gouliamos A, Rizos D (1997). “MRI and ultrasonographic findings in the investigation of lymphedema and lipedema”. Int Surg. 82 (4): 411–6. PMID 9412843.

[pmid24947530-5] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). “Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America”. Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.

[pmid27434444-6] Raff AB, Kroshinsky D (2016). “Cellulitis: A Review”. JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.

[pmid10834819-7] Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY (2000). “Cellulitis complicating lymphoedema”. Eur J Clin Microbiol Infect Dis. 19 (4): 294–7. PMID 10834819.

[pmid4005155-8] Leppard BJ, Seal DV, Colman G, Hallas G (1985). “The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas”. Br J Dermatol. 112 (5): 559–67. PMID 4005155.

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