Pulmonary Embolism (PE) Differential Diagnoses

Updated: Sep 18, 2020
  • Author: Daniel R Ouellette, MD, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Diagnostic Considerations

The variability of presentation for pulmonary embolism (PE) sets the patient and clinician up for potentially missing the diagnosis. Such missed diagnoses occur in approximately 400,000 patients in the United States per year; approximately 100,000 deaths could be prevented with proper diagnosis and treatment.

The diagnostic challenge is that the "classic" presentation of the condition, with abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia, is rarely seen. Studies of patients who died unexpectedly from PE have revealed that the patients complained of nagging symptoms, often for weeks, before dying. Forty percent of these patients had been seen by a physician in the weeks prior to their death. [7]

The differential diagnoses are extensive, and they should be considered carefully with any patient thought to have pulmonary embolism. These patients also should have an alternative diagnosis confirmed, or pulmonary embolism should be excluded, before discontinuing the workup. Additional problems to be considered include the following:

  • Musculoskeletal pain

  • Pleuritis

  • Pericarditis

  • Salicylate intoxication

  • Hyperventilation

  • Silicone pulmonary embolism [44]

  • Lung trauma

  • Mediastinitis, acute

Sickle cell disease

Sickle cell disease often creates a diagnostic difficulty with regard to pulmonary embolism. A chest infection is often the presenting symptom. Hypoxemia, dehydration, and fever lead to intravascular sludging within pulmonary (among others) vasculature. This promotes a vicious cycle, further exacerbating local hypoxemia, ultimately leading to local tissue infarction. This process is further worsened by bone marrow infarction, which may cause release of fat emboli that lodge in the pulmonary circulation. [45]

Differential Diagnoses