This new title in the ABC series covers the assessment, diagnosis, treatment, and management of the most common symptoms with 'walk through' diagnosis, clear learning outcomes, and easy to find treatment options.
abc of differential diagnosis pdf download
Distinguishing CD from ITB is challenging as both diseases have similar radiological, endoscopic, and histologic features. A high index of suspicion is paramount as otherwise it may result in medical mishap. In case of misdiagnosis of ITB, unnecessary anti-tubercular drugs pose a risk of toxicity and treatment of the actual disease is delayed. In contrast, treatment with steroids and immunosuppressants for a mistaken diagnosis of CD can lead to fatal dissemination of tuberculosis. It is well known that the differentiation of CD from ITB cannot be made on single index evaluation of a patient as no single pathognomonic test is available for either of the two diseases. Hence, all clinical and diagnostic evidences need to be considered for reaching at the diagnosis. This review discusses various parameters that aid in differentiating between two closely resembling diseases.
Ileo colonoscopy is crucial for the diagnosis of both ITB and CD as brunt of disease in both conditions is around the ileocecal area. When ITB affects the colon, it can present in various ways as segmental ulcers, inflammatory strictures, or hypertrophic lesions resembling nodules, polyps, and masses (Fig. 1). ITB is seen more in the right side of the colon and follows a decreasing trend from the right to left side of the colon [17, 18]. Rarely diffuse involvement of colon resembling pancolitis may occur in ITB. Anorectal involvement, aphthous ulcers, deep longitudinal ulcers, and cobblestone appearance were all significantly more common in patients with CD than in patients with ITB [19] (Fig. 2). Predominant ileal involvement with sparing of cecum is likely to occur in CD rather than ITB where IC valve gets involved early. Similarly, early involvement of multiple segments will favor the diagnosis of CD rather than ITB. The extent of ileal involvement in ITB is shorter as compared to CD. In contrast, ITB usually has less than four segments involved, a patulous ileocecal valve, transverse ulcers, and more scars.
This skin test has been extensively studied in patients with pulmonary tuberculosis. The traditional cut-off used is 10 mm. But increasing this to 15 mm increases the specificity but at the cost of sensitivity [30]. The value of this test specifically for ITB is not established. False-positive results may occur due to previous BCG vaccine exposure (up to 15 years), non-tuberculosis mycobacteria, and in low endemicity areas. Similarly, false-negative results may occur in patients on immunosuppressants, extreme malnutrition, and other immunocompromised states. However, this test, if positive, provides supportive evidence to the diagnosis of tuberculosis though negative test does not rule out the disease.
The main advantages of these tests are (i) no cross-reaction with BCG and most non-tuberculosis mycobacteria, (ii) complete in a single visit, and (iii) malnourished and immunocompromised patients can be evaluated. However, these assays fail to differentiate between latent and active tuberculosis and cannot predict progression of latent tuberculosis. In case of borderline values of IGRA, one has to rely more on TST and clinical judgment [33]. The precise role of these assays in the diagnosis of TB remains unsettled.
Differentiation between ITB and CD is very challenging but crucial as fall outs of wrong diagnosis can be devastating. In the absence of a single pathognomonic clinical feature or diagnostic test, the diagnosis of either disease should be based on all the evidences. A detailed clinical evaluation and corroborative tests are mandatory before initiating specific therapy.
Psychogenic nonepileptic seizures present as paroxysmal symptoms and signs mimicking epileptic seizures. The gold standard test is the synchronous recording by video, electrocardiogram and electroencephalogram. However, video electroencephalogram is not available at many centers and not entirely independent of semiology. Recent studies have focused on semiological characteristics distinguishing these two circumstances. Clinical signs and symptoms provide important clues when making differential diagnosis. The purpose of this review is to help physicians differentiating psychogenic nonepileptic seizures better from epileptic seizures based on semiology, and improve care for those patients.
Beyond the gait difficulties, all patients presented with normal neurological examination, a clinical turning point in the differential diagnosis of patients presenting with acute onset of gait abnormalities.
Table 3 shows the main causes of gait abnormalities and/or acute legs pain in children in differential diagnosis with BACM. Among them, Guillain Barrè syndrome (GBS) needs to be promptly recognized, given the possibility of setting up a timely therapy. This is particularly true for younger patients who are unable by age to clearly express symptoms, with mild serum CK increase and even if the osteotendon reflexes are preserved [17]. In these cases, a neurophysiological study should be considered.
Within the flow chart, some red flags must be carefully considered by clinicians since they represent clinical findings suggesting alternative severe diagnosis or elements which need different clinical management. 2ff7e9595c
Comments