Table Of Content

For Evaluation Only. Copyright (c) by Foxit Software Company, 2004 Edited by Foxit PDF Editor I Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. II Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. III Differential Diagnosis in Internal Medicine From Symptom to Diagnosis Walter Siegenthaler, MD Professor Emeritus of Internal Medicine University of Zürich Zürich, Switzerland With contributions by A. Aeschlimann, E. Baechli, C. Bassetti, E. Battegay, M. Battegay, K. Bloch, H.E. Blum, F. Duru, F.R. Eberli, T. Fehr, A. Fontana, M. Fox, M. Fried, K. Hess, U. Hoffmann, D. Jaeger, M. Kraenzlin, H. Kupferschmidt, S. Lautenschlager, B. Michel, E. Oechslin, P. Ott, P. Peghini, E.W. Russi, N. Schaefer, C. Scharf, C. Schmid, U. Schwarz, G.A. Spinas, S. Stoeckli, F. Tató, A. von Eckardstein, R. Weber, R.P. Wuethrich Specialist Consultants A. Aeschlimann: Rheumatology M. Battegay: Fundamentals of Differential Diagnosis H.E. Blum: Gastroenterology, Hepatology F.R. Eberli: Cardiology P. Greminger: General Internal Medicine K. Hess: Neurology A. Knuth: Hematology, Oncology E.W. Russi: Pneumology G.A. Spinas: Endocrinology, Diabetology R. Weber: Infectiology R.P. Wuethrich: Nephrology 789 illustrations 323 tables Thieme Stuttgart · New York Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. IV Library of Congress Cataloging-in-Publication Data Siegenthalers Differentialdiagnose. English. Differential diagnosis in internal medicine / [edited by] Walter Siegenthaler ; with contributions by A. Aeschlimann ... [et al.] ; specialist consultants, A. Aeschlimann ... [et al.]. -- 1st English ed. p. ; cm. ISBN 978-3-13-142141-8 (TPS : alk. paper) -- ISBN 978-1-58890-551-2 (TPN : alk. paper) 1. Diagnosis, Differential. 2. Physical diagnosis. 3. Internal medicine. I. Siegenthaler, Walter, 1923- II. Title. [DNLM: 1. Diagnosis, Differential. 2. Internal Medicine. WB 141.5 S571 2007a] RC71.D5447 2007 616.07'5--dc22 2007004243 This first English edition is a revised and updated authorized translation of the 19th German edition pub- lished and copyrighted 2005 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Siegen- thalers Differentialdiagnose: Innere Krankheiten − vom Symptom zur Diagnose. © 2007 Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA http://www.thieme.com Illustrator: Joachim Hormann, Stuttgart, Germany; Plankensteiner + Hanig, Esslingen, Germany; Andrea Schnitzler, Innsbruck, Austria Cover design: Thieme Publishing Group Typesetting by primustype Hurler, Notzingen, Germany Printed in Germany by APPL, aprinta druck, Wemding, Germany ISBN 978-3-13-142141-8 (TPS, Rest of World) ISBN 978-1-58890-551-2 (TPN, The Americas) 1 2 3 4 5 6 Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or appli- cation, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applica- tions stated in the book. Every user is requested to ex- amine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules men- tioned therein or the contraindications stated by the manu- facturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly re- leased on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and re- sponsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccura- cies noticed. If errors in this work are found after publica- tion, errata will be posted at www.thieme.com on the pro- duct description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appear- ance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to pros- ecution. This applies in particular to photostat reproduc- tion, copying, mimeographing, preparation of microfilms, and electronic data processing and storage. Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. V Preface The present book, Differential Diagnosis in Internal Medicine, first appeared as a German edition in 1952 and since then has been translated into 10 other languages. Over the past 50 years 19 Ger- man editions have been published, and now the 19th edition of the work, which has become the classic differential diagnosis textbook, is available in English for the first time. This book encompasses differential diagnosis across the spectrum of internal medicine, cover- ing dermatology, neurology, and rheumatology, and provides the very latest knowledge including pathophysiological aspects. In contrast to ency- clopedically structured textbooks, this book traces the path from symptom to diagnosis, just as the physician encounters the situation in the hospital and in the office. With this pragmatic approach—starting from the symptom(s)—the physician will usually suc- ceed in substantiating the suspected diagnosis. Using this method, Siegenthaler’s Differential Di- agnosis in Internal Medicine guides the reader through the differential diagnostic challenges in the entire field of internal medicine, including dermatology, neurology, and rheumatology. The book incorporates many relevant and instructive illustrations, tables, graphics, and algorithms, all contributing to the process of narrowing down a definitive diagnosis. The book is intended for medical students, phy- sicians in clinical practice, generalists, and special- ists in internal medicine, dermatology, neurology, and rheumatology, and also for all those concerned with the fundamental subjects of medicine, who wish to gain a competent knowledge of internal medicine. My thanks are due to all of the colleagues who worked with me on the book, and also to Thieme Publishing Group, in particular Thieme Publishers Stuttgart. I hope that, with the launch of the Eng- lish edition, this classic textbook of differential di- agnosis in internal medicine will now also find its place in the English-speaking world. Walter Siegenthaler, MD Professor Emeritus of Internal Medicine University of Zürich Zürich, Switzerland Preface Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. VI Contributors Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. VII Foreword Foreword I first met Professor Walter Siegenthaler in the 1970s while he was at the University of Zürich, where both he and his late wife, the superb clini- cian Doctor Gertrud Siegenthaler-Zuber, were ad- mired for their many accomplishments and dedi- cation to the advancement of medicine. At that time, Professor Siegenthaler helped me establish a program to bring cardiologists from the Baylor College of Medicine and the Methodist Hospital in Houston, Texas, to Switzerland to study the pioneering balloon angioplasty work of Andreas Gruentzig. Subsequently, he honored us by serv- ing as a Visiting Professor at Baylor, exemplifying the best of Swiss medicine. Now, 30 years later, Professor Siegenthaler remains at the leading edge of medicine, as this expertly realized book in your hands attests. Differential diagnosis is the fundamental meth- odology of modern clinical medicine: we note the patient’s symptoms; we develop hypotheses for the affliction and propose treatment; and we ad- just treatment based on the patient’s response. Thus, differential diagnosis requires the physician to be observant, knowledgeable, thoughtful, thorough, and organized, qualities that could also be used to describe the conceptualization and ex- ecution of the following pages. In the last few de- cades, we have seen stunning advances in the level of clinical care and diagnostic procedures available across the spectrum of human diseases. The sophistication of contemporary nosology is truly impressive. On the other hand, the rapid turnover of medi- cal information can prove daunting to many clini- cians, and the application of the latest evidence to our daily interactions with patients may seem un- clear or too complex. Siegenthaler’s Differential Diagnosis in Internal Medicine reminds us to ap- proach diagnostic problems in a practical, system- atic, and critical manner, remembering that each patient’s circumstance is unique and that it is every doctor’s responsibility to exercise his or her best educated judgment to present rational choices about the most probable diagnoses and optimal treatment courses. Occam’s Razor, which advises us that the simplest explanation is usually the correct one, all things being equal, is an im- portant precept in diagnostic medicine, yet doc- tors must also be flexible and adaptable to the ec- centricities of every case. Thus, physicians should not expect to see a zebra when confronted with a horse, but they should be able to recognize the zebra on the rare occasion that it makes an ap- pearance. I believe that the scholarship, clinical skill, and practical wisdom that Professor Siegenthaler and his colleagues share with us in this text are indis- pensable resources for the medical community. The wealth of illustrative photographs, informa- tive tables, and up-to-date discussion of issues in internal medicine will prove very useful in daily clinical practice. Antonio M. Gotto, Jr., MD, DPhil The Stephen and Suzanne Weiss Dean Professor of Medicine Weill Cornell Medical College Provost for Medical Affairs Cornell University New York, USA Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. VIII Contributors Contributors Editor Prof. Dr. med. Dr. h. c. Walter Siegenthaler Forsterstr. 61 8044 Zürich, Switzerland Authors André Aeschlimann, MD Professor RehaClinic Zurzach Zurzach, Switzerland Esther Baechli, MD Spital Uster Medical Clinic Uster, Switzerland Claudio Bassetti, MD Professor University Hospital Zürich Clinic and Policlinic for Neurology Zürich, Switzerland Edouard Battegay, MD Professor University Hospital Basel Medical Policlinic Basel, Switzerland Manuel Battegay, MD Professor University Hospital Basel Department of Medicine Division of Infectiology Basel, Switzerland Peter Bauerfeind, MD Associate Professor University Hospital Zürich Departement of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Konrad Bloch, MD Professor University Hospital Zürich Department of Internal Medicine Division of Pneumology Zürich, Switzerland Hubert E. Blum, MD Professor and Director Department of Internal Medicine II University Medical Center Freiburg, Germany Thomas Bombeli, MD Associate Professor Research and Development Novo Nordisk S/A Bagsvaerd, Denmark Firat Duru, MD Professor University Hospital Zürich Department of Internal Medicine Division of Cardiology Cardiovascular Center Zürich, Switzerland Franz Eberli, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Cardiology Cardiovascular Center Zürich, Switzerland Joerg Fehr, MD Professor University Hospital Zürich Department of Internal Medicine Division of Hematology Zürich, Switzerland Thomas Fehr, MD Associate Professor Center for Nephrology University Hospital Zürich Zürich, Switzerland Adriano Fontana, MD Professor University Hospital Zürich Faculty of Medicine Department of Internal Medicine Division of Clinical Immunology Zürich, Switzerland Mark Fox, MD Research Consultant University Hospital Zürich Zürich, Switzerland Michael Fried, MD Professor University Hospital Zürich Department of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Peter Greminger, MD Professor St Gallen Canton Hospital Department of Internal Medicine St Gallen, Switzerland Klaus Hess, MD Professor University Hospital Zürich Clinic and Policlinic for Neurology Zürich, Switzerland Ulrich Hoffmann, MD Professor University of Munich Hospital Vascular Center—Angiology Munich, Germany Sabina Hunziker, MD University Hospital Basel Medical Policlinic Basel, Switzerland Dirk Jaeger, MD Associate Professor Director of Clinical Oncology National Center for Tumor Diseases Heidelberg, Germany Alexander Knuth, MD Professor University Hospital Zürich Clinic and Policlinic for Oncology Zürich, Switzerland Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. IX Marius Kraenzlin, MD Associate Professor Basel, Switzerland Hugo Kupferschmidt, MD Swiss Toxicology Information Center (STIZ) Zürich, Switzerland Stephan Lautenschlager, MD Associate Professor Dermatology Clinic Stadtspital Triemli Zürich, Switzerland Hans-Peter Marti, MD Professor University Hospital Zürich Department of Internal Medicine Division of Nephrology Zürich, Switzerland Benedict Martina, MD Associate Professor Basel University Hospital Medical Policlinic Basel, Switzerland Darius Moradpour, MD Professor Vaudois University Hospital Gastroenterology and Hepatology Service Lausanne, Switzerland Beat Muellhaupt, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Beat A. Michel, MD Professor University Hospital Zürich Rheumatism Clinic and Instititute of Physical Medicine Zürich, Switzerland Erwin Oechslin, MD Professor Director Congenital Cardiac Centre for Adults University Health Network Toronto, Canada Peter Ott, MD Professor University Hospital Zürich Otorhinolaryngology Policlinic Zürich, Switzerland Pietro Peghini, MD University Hospital Zürich Department of Internal Medicine Division of Hematology Zürich, Switzerland Erich W. Russi, MD Professor University Hospital Zürich Department of Internal Medicine Division of Pneumology Zürich, Switzerland Niklaus Schaefer, MD University Hospital Zürich Clinic and Policlinic for Oncology Zürich, Switzerland Urs Schanz, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Hematology Zürich, Switzerland Christoph Scharf, MD Associate Professor Klinik im Park Zürich, Switzerland Christoph Schmid, MD Professor University Hospital Zürich Department of Internal Medicine Division of Endocrinology and Diabetology Zürich, Switzerland Urs Schwarz, MD Associate Professor University Hospital Zürich Clinic and Policlinic for Neurology Zürich, Switzerland Werner Schwizer, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Giatgen A. Spinas, MD Professor University Hospital Zürich Department of Internal Medicine Division of Endocrinology and Diabetology Zürich, Switzerland S. Stoeckli, MD Associate Professor University Hospital Zürich Otorhinolaryngology Clinic Zürich, Switzerland Federico Tató, MD Associate Professor University of Munich Hospital Vascular Center—Angiology Munich, Germany Miriam Thumshirn, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Arnold von Eckardstein, MD Professor University Hospital Zürich Institute of Clinical Chemistry Zürich, Switzerland Rainer Weber, MD Professor University Hospital Zürich Department of Internal Medicine Division of Infectious Diseases and Hospital Hygiene Zürich, Switzerland Rudolf P. Wuethrich, MD Professor University Hospital Zürich Department of Internal Medicine Division of Nephrology Zürich, Switzerland Contributors Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. X Contents 1−3 General Differential Diagnosis 1 General Aspects of Diagnosis and Differential Diagnosis . . . . . . . . . . . . . . . . 2 M. Battegay, B. Martina, and E. Battegay 1.1 Elements of the Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Disease and Differential Diagnosis . . . . . . . . . . . . 4 Practical Procedure for Establishing a Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Correct Evaluation of Evident Findings and the Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . 6 How to Handle Errors in the Medical Field . . . . 9 Factors That Can Lead to False Diagnoses . . . . . 10 Physician-specific Problems . . . . . . . . . . . . . . . . . 10 Patient-specific Problems . . . . . . . . . . . . . . . . . . . 10 1.2 Factors That Can Influence the Differential Diagnostic Thought Process . . . . . . . . . . . . 11 Prevalence of Diseases . . . . . . . . . . . . . . . . . . . . . . . . 11 Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Eating Habits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Season, Time of Day, and Weather . . . . . . . . . . . . 14 Geographic Distribution . . . . . . . . . . . . . . . . . . . . . . 14 Ethnic Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Profession and Leisure . . . . . . . . . . . . . . . . . . . . . . . . 14 Precluding or Promoting Diseases . . . . . . . . . . . . 16 1.3 Differential Diagnosis by Groups of Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Degenerative Conditions . . . . . . . . . . . . . . . . . . . . . . 16 Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Immune Mediated Diseases . . . . . . . . . . . . . . . . . . . 17 Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Metabolic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Dysfunction of the Endocrine System . . . . . . . . . 20 Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Hereditary Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Chromosome Anomalies . . . . . . . . . . . . . . . . . . . . 21 Simple Mendelian Genetics . . . . . . . . . . . . . . . . . 21 Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Multifactorial Heredity . . . . . . . . . . . . . . . . . . . . . 22 Intoxications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2 History, Physical Examination, and Important Subjective Complaints . . 24 E. Battegay, S. Hunziker, and G.A. Spinas 2.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Greeting and Interview Setting . . . . . . . . . . . . . . . . 26 Components of the Clinical Interview . . . . . . . . . 26 2.2 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Thyroid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . 27 Chest and Lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Percussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Auscultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . 31 Neurological Examination . . . . . . . . . . . . . . . . . . . . 32 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. XI 2.3 The Asymptomatic Patient (Checkup) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Disease Prevention in Healthy Persons . . . . . . . . 33 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Screening and Differential Diagnosis in Apparently Healthy Persons . . . . . . . . . . . . . . . . . . 34 Periodic Health Exams . . . . . . . . . . . . . . . . . . . . . . 34 Case Finding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Hidden Agendas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 2.4 Important Subjective Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Appetite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Thirst/Polydipsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Definition of Diabetes Mellitus . . . . . . . . . . 38 Type 1 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . 39 Type 2 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . 39 Specific Types of Diabetes . . . . . . . . . . . . . . . 39 Gestational Diabetes . . . . . . . . . . . . . . . . . . . . 39 Complications of Diabetes Mellitus . . . . . . 40 Diabetes Insipidus . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Central Diabetes Insipidus . . . . . . . . . . . . . . . 40 Renal Diabetes Insipidus . . . . . . . . . . . . . . . . 40 Primary Polydipsia . . . . . . . . . . . . . . . . . . . . . . . . . 41 Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Hemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Palpitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Hiccups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 3 Skin and External Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 S. Lautenschlager, M. Battegay, and G.A. Spinas 3.1 Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Method of Examination . . . . . . . . . . . . . . . . . . . . . . . 53 Clinical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Skin Color . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Pallor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Redness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Discoloration . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Disturbances of Pigmentation . . . . . . . . . . . 54 Erythema and Exanthems . . . . . . . . . . . . . . . . . . 56 Vesicular Skin Diseases . . . . . . . . . . . . . . . . . . . . . 57 Bullous Skin Diseases . . . . . . . . . . . . . . . . . . . . . . . 59 Papular Skin Diseases . . . . . . . . . . . . . . . . . . . . . . 60 Plaque-forming Skin Diseases . . . . . . . . . . . . . . 60 Nodular Skin Diseases . . . . . . . . . . . . . . . . . . . . . . 60 Pustular Skin Diseases . . . . . . . . . . . . . . . . . . . . . . 61 Ulcerations of the Skin . . . . . . . . . . . . . . . . . . . . . 62 Urticarial Skin Diseases . . . . . . . . . . . . . . . . . . . . . 63 Purpura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Telangiectasias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Disturbances of Skin Turgor . . . . . . . . . . . . . . . . 64 Calcifications of the Skin . . . . . . . . . . . . . . . . . . . 64 Skin Changes Due to Systemic Disease . . . . . . . . 65 Skin Changes Due to Metabolic Disorders . . . . 65 Skin Changes Due to Endocrine Disorders . . . 66 Skin Changes Due to Tumors . . . . . . . . . . . . . . . . 66 Skin Changes Due to Collagenoses . . . . . . . . . . 67 Skin Changes as Adverse Effects of Medications and Intoxications . . . . . . . . . . . . . . 68 Skin Changes Due to Hematologic Diseases . . 68 Skin Changes Due to Gastrointestinal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Skin Changes Due to Hepatic Diseases . . . . . . . 69 Skin Changes Due to Heart Disease . . . . . . . . . . 69 Neurocutaneous Diseases . . . . . . . . . . . . . . . . . . . 69 Skin Changes Due to Infection . . . . . . . . . . . . . . 71 Hair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Hair Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Hirsutism and Virilism . . . . . . . . . . . . . . . . . . . . . 73 Pigmentation Disorders . . . . . . . . . . . . . . . . . . . . . 73 Nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Changes in Nail Shape and Structure . . . . . . . . 74 Nail Discoloration . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Oral Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Changes of the Teeth . . . . . . . . . . . . . . . . . . . . . . . 76 Changes of the Gums . . . . . . . . . . . . . . . . . . . . . . . 77 Changes of the Oral Mucosa . . . . . . . . . . . . . . . . 77 Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. XII 3.2 External Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Stature and Posture . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Tall Stature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Tall Stature Due to Congenital Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Tall Stature Due to Endocrine Disorders . . 80 Short Stature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Short Stature Due to Congenital Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Short Stature Due to Skeletal Dysplasias . 83 Short Stature Due to Chronic Diseases and Malabsorption Syndromes . . . . . . . . . . 83 Short Stature Due to Endocrine Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Standing Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Lying Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Primary Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Secondary Obesity . . . . . . . . . . . . . . . . . . . . . . . . . 87 Localized Collections of Fat and Lipody- strophies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Gynecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Anorexia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Hands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Exophthalmos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Horner Syndrome, Enophthalmos . . . . . . . . . . . 94 Eyebrows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Eyelids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Sclerae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Cornea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Iris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Pupil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Vitreous Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Retina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 The Red Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Ocular Motility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Ears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Odor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Language, Speech, and Phonation . . . . . . . . . . . . . 100 Disturbances of Language and Speech . . . . . . . 100 Disturbances of Phonation . . . . . . . . . . . . . . . . . . 102 4 Fever 4 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 R. Weber and A. Fontana 4.1 General Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Medical History and Clinical Findings . . . . . . . . . 111 Differential Diagnostic Considerations . . . . . . . . 111 Fever of Unknown Origin . . . . . . . . . . . . . . . . . . . . . 113 4.2 Fever without Localized Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Noninfectious Causes . . . . . . . . . . . . . . . . . . . . . . . . . 115 Hospitalized Patients . . . . . . . . . . . . . . . . . . . . . . . . . 116 4.3 Fever with Associated Cardinal Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Fever and Skin Rashes . . . . . . . . . . . . . . . . . . . . . . . . 116 Petechiae and Purpura . . . . . . . . . . . . . . . . . . . . . 116 Maculopapular Exanthema . . . . . . . . . . . . . . . . . 118 Vesicles and Pustules . . . . . . . . . . . . . . . . . . . . . . . 118 Nodular Skin Lesions . . . . . . . . . . . . . . . . . . . . . . . 118 Erythema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Urticaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Bacterial Skin Infections . . . . . . . . . . . . . . . . . . . . 119 Mycobacterial Skin Infections . . . . . . . . . . . . . . . 120 Rickettsial Diseases . . . . . . . . . . . . . . . . . . . . . . . . 121 Viral Diseases with Skin Rashes . . . . . . . . . . . . . 122 Fever and Joint or Bone Pain . . . . . . . . . . . . . . . . . . 125 Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Osteomyelitis, Spondylodiscitis, and Joint Prostheses Infections . . . . . . . . . . . . . . . . . . . . . . . 126 Fever and Lymph Node Enlargement . . . . . . . . . . 127 Fever and Generalized Lymph Node Enlargement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Fever and Localized Lymph Node Enlargement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Infections of the Lymph Nodes . . . . . . . . . . . . . . 128 Lymphadenopathy of Unknown Origin . . . . . . 129 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. XIII Fever and Swelling of the Face or Neck . . . . . . . 130 Parotid Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Neck Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Fever, Headaches, and Neck Stiffness . . . . . . . . . . 131 Examination of the Cerebrospinal Fluid (CSF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Bacterial Meningitis . . . . . . . . . . . . . . . . . . . . . . . . 133 Serous Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Fungal Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Meningitis Caused by Protozoa or Helminths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Concomitant Cases of Meningitis . . . . . . . . . . . . 135 Fever and Neurological Deficits . . . . . . . . . . . . . . . 136 Encephalitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Cerebral Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Subdural Empyema, Epidural Abscess . . . . . . . 138 Fever with Common Cold Symptoms . . . . . . . . . . 138 Bacterial Tonsillitis and Pharyngitis . . . . . . . . . 138 Nonbacterial Pharyngitis . . . . . . . . . . . . . . . . . . . 138 Common Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Otitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Epiglottitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Fever, Cough, and Thoracic Pain . . . . . . . . . . . . . . 141 Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Nontuberculous Mycobacterioses . . . . . . . . . . . 144 Nocardiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Pericarditis, Myocarditis . . . . . . . . . . . . . . . . . . . . 145 Noninfectious Diseases . . . . . . . . . . . . . . . . . . . . . 145 Fever and Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Prehepatic Jaundice . . . . . . . . . . . . . . . . . . . . . . . . 145 Hepatic Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Posthepatic Jaundice . . . . . . . . . . . . . . . . . . . . . . . 147 Fever and Splenomegaly . . . . . . . . . . . . . . . . . . . . . . 146 Fever and Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Intestinal Infections . . . . . . . . . . . . . . . . . . . . . . . . 147 Pathogens Causing Diarrhea . . . . . . . . . . . . . . . . 148 Fever and Abdominal Pain . . . . . . . . . . . . . . . . . . . . 149 Intra-abdominal Infections . . . . . . . . . . . . . . . . . 149 Peritonitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Intra-abdominal Abscesses . . . . . . . . . . . . . . . . . 150 Visceral Abscesses . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Specific Causes of Intra-abdominal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Fever, Dysuria, and Pollakisuria . . . . . . . . . . . . . . . 151 Urethritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Acute Uncomplicated Urinary Tract Infections in Women . . . . . . . . . . . . . . . . . . . . . . . 151 Acute Uncomplicated Pyelonephritis . . . . . . . . 151 Acute Complicated Pyelonephritis . . . . . . . . . . . 152 Prostatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Fever and Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Systemic Inflammatory Response Syndrome (SIRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Bacteremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Sources of Sepsis, Predisposition . . . . . . . . . . . . 153 Selected Sepsis Pathogens . . . . . . . . . . . . . . . . . . 153 Fever and Heart Defects . . . . . . . . . . . . . . . . . . . . . . 155 Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Other Endovascular Infections . . . . . . . . . . . . . . 156 4.4 Fever with Multiple Organ Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Viral Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Cytomegalovirus Infection . . . . . . . . . . . . . . . . . . 157 Tickborne Infections . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Lyme Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Ehrlichiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Babesiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Sexually Transmitted Infections . . . . . . . . . . . . . . . 159 Syphilis (Treponema pallidum) . . . . . . . . . . . . . . 159 Chlamydia trachomatis . . . . . . . . . . . . . . . . . . . . . 161 Zoonosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Brucellosis (Brucella melitensis, B. abortus, B. suis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Leptospirosis (Leptospira interrogans [Weil disease] and other serotypes) . . . . . . . . . . . . . . . 162 Toxoplasmosis (Toxoplasma gondii) . . . . . . . . . 162 Trichinosis (Trichinella spiralis) . . . . . . . . . . . . . . 162 Toxocara Infection . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Rabies (Rhabdoviruses) . . . . . . . . . . . . . . . . . . . . . 163 Other Infections Caused by Animal Bites . . . . . 163 Infections by Arboviruses . . . . . . . . . . . . . . . . . . . 163 HIV Infection and AIDS . . . . . . . . . . . . . . . . . . . . . . . 163 Acute HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . 163 Asymptomatic HIV Infection . . . . . . . . . . . . . . . . 164 Symptomatic HIV Infection, AIDS . . . . . . . . . . . 164 Infections in Immunocompromised Persons . . 167 Opportunistic Viral Infections . . . . . . . . . . . . . . . 168 Opportunistic Bacterial Infections . . . . . . . . . . . 168 Opportunistic Fungal Infections . . . . . . . . . . . . . 168 Opportunistic Protozoa and Helminths . . . . . . 169 Mycoses in Localized Endemic Regions . . . . . . . . 170 Coccidioidomycosis (Coccidioides immitis) . . . 170 Histoplasmosis (Histoplasma capsulatum) . . . . 171 Travel and Tropical Diseases . . . . . . . . . . . . . . . . . . 170 Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Leishmaniasis (Leishmania donovani) . . . . . . . . 172 Schistosomiasis (Bilharziosis) . . . . . . . . . . . . . . . 173 Lymphatic Filariasis . . . . . . . . . . . . . . . . . . . . . . . . 174 Tissue Filariases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Dengue Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Yellow Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Other Tropical Diseases . . . . . . . . . . . . . . . . . . . . . 175 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. XIV 4.5 Fever in Autoimmune Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Localized or Organ-Specific Autoimmune Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Generalized Autoimmune Disease, Vasculitis, and Connective Tissue Syndrome . . . . . . . . . . . . . 176 Vasculitis of Large Vessels . . . . . . . . . . . . . . . . . . . . 178 Giant Cell Arteritis (Arteritis Temporalis Horton) and Polymyalgia Rheumatica Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Vasculitis of Medium-Sized Vessels . . . . . . . . . . . 178 Polyarteritis Nodosa or Panarteritis . . . . . . . . . 178 Vasculitis of Small Vessels . . . . . . . . . . . . . . . . . . . . 180 Wegener Granulomatosis . . . . . . . . . . . . . . . . . . . 180 Allergic Granulomatosis (Churg−Strauss Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Hypersensitivity Vasculitis . . . . . . . . . . . . . . . . . . 181 Purpura−Arthralgia−Nephritis Syndrome . . . . 181 Systemic Lupus Erythematosus (SLE) . . . . . . . . 181 Scleroderma (Progressive Diffuse or Generalized Scleroderma or Progressive Systemic Sclerosis [PSS]) . . . . . . . . . . . . . . . . . . . 183 Circumscribed Scleroderma . . . . . . . . . . . . . . . . . 184 Scleroederma Adultorum (Buschke Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Eosinophilic Fasciitis (Shulman Syndrome) . . 186 Sharp Syndrome, Overlap Syndrome (Mixed Connective Tissue Disease [MCTD]) . . 186 Dermatomyositis (Polymyositis) . . . . . . . . . . . . 186 4.6 Fever in Immune Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Classification of Immune Deficiency . . . . . . . . . . 187 Humoral Immune Deficiencies (B-cell Deficiencies) . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Cellular Immune Deficiencies (T cell Deficiencies) . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Combined Humoral and Cellular Immune Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Defects of the Complement System . . . . . . . . . . . 191 Defects of Phagocytosis . . . . . . . . . . . . . . . . . . . . . . 191 4.7 Fever in Various Noninfectious Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Periodic Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Familial Mediterranean Fever . . . . . . . . . . . . . . . 192 Hyper-IgD Syndrome . . . . . . . . . . . . . . . . . . . . . . . 192 Tumor Necrosis Factor Receptor-associated Periodic Fever Syndrome (TRAPS) . . . . . . . . . . . 193 “PFAPA” Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . 193 Fever in Endocrine Disorders . . . . . . . . . . . . . . . . . 193 Fever in Vegetative Dystonia . . . . . . . . . . . . . . . . . . 193 Chronic Mercury Intoxication . . . . . . . . . . . . . . . . . 193 Chronic Fatigue Syndrome . . . . . . . . . . . . . . . . . . . . 193 Fever in Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Fever in Tissue Degradation . . . . . . . . . . . . . . . . . . . 194 Fever in Hemolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Hemophagocytosis Syndrome . . . . . . . . . . . . . . . . . 195 Fever in Thrombosis and Thrombophlebitis . . . 195 Fever in Allergic Reactions . . . . . . . . . . . . . . . . . . . . 195 Simulated Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 4.8 Significance of Individual Findings for the Differentiation of Febrile States . . . . . . . . . 195 Course of the Temperature . . . . . . . . . . . . . . . . . . . 195 Chills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Inflammation Parameters . . . . . . . . . . . . . . . . . . . . 196 Erythrocyte Sedimentation Rate (ESR) . . . . . . . 196 C-reactive Protein (CRP) . . . . . . . . . . . . . . . . . . . . 197 Procalcitonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Blood Count . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Leukocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Eosinophils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Monocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Lymphocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. 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For Evaluation Only. Copyright (c) by Foxit Software Company, 2004 Edited by Foxit PDF Editor I Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. II Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. III Differential Diagnosis in Internal Medicine From Symptom to Diagnosis Walter Siegenthaler, MD Professor Emeritus of Internal Medicine University of Zürich Zürich, Switzerland With contributions by A. Aeschlimann, E. Baechli, C. Bassetti, E. Battegay, M. Battegay, K. Bloch, H.E. Blum, F. Duru, F.R. Eberli, T. Fehr, A. Fontana, M. Fox, M. Fried, K. Hess, U. Hoffmann, D. Jaeger, M. Kraenzlin, H. Kupferschmidt, S. Lautenschlager, B. Michel, E. Oechslin, P. Ott, P. Peghini, E.W. Russi, N. Schaefer, C. Scharf, C. Schmid, U. Schwarz, G.A. Spinas, S. Stoeckli, F. Tató, A. von Eckardstein, R. Weber, R.P. Wuethrich Specialist Consultants A. Aeschlimann: Rheumatology M. Battegay: Fundamentals of Differential Diagnosis H.E. Blum: Gastroenterology, Hepatology F.R. Eberli: Cardiology P. Greminger: General Internal Medicine K. Hess: Neurology A. Knuth: Hematology, Oncology E.W. Russi: Pneumology G.A. Spinas: Endocrinology, Diabetology R. Weber: Infectiology R.P. Wuethrich: Nephrology 789 illustrations 323 tables Thieme Stuttgart · New York Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. IV Library of Congress Cataloging-in-Publication Data Siegenthalers Differentialdiagnose. English. Differential diagnosis in internal medicine / [edited by] Walter Siegenthaler ; with contributions by A. Aeschlimann ... [et al.] ; specialist consultants, A. Aeschlimann ... [et al.]. -- 1st English ed. p. ; cm. ISBN 978-3-13-142141-8 (TPS : alk. paper) -- ISBN 978-1-58890-551-2 (TPN : alk. paper) 1. Diagnosis, Differential. 2. Physical diagnosis. 3. Internal medicine. I. Siegenthaler, Walter, 1923- II. Title. [DNLM: 1. Diagnosis, Differential. 2. Internal Medicine. WB 141.5 S571 2007a] RC71.D5447 2007 616.07'5--dc22 2007004243 This first English edition is a revised and updated authorized translation of the 19th German edition pub- lished and copyrighted 2005 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Siegen- thalers Differentialdiagnose: Innere Krankheiten − vom Symptom zur Diagnose. © 2007 Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA http://www.thieme.com Illustrator: Joachim Hormann, Stuttgart, Germany; Plankensteiner + Hanig, Esslingen, Germany; Andrea Schnitzler, Innsbruck, Austria Cover design: Thieme Publishing Group Typesetting by primustype Hurler, Notzingen, Germany Printed in Germany by APPL, aprinta druck, Wemding, Germany ISBN 978-3-13-142141-8 (TPS, Rest of World) ISBN 978-1-58890-551-2 (TPN, The Americas) 1 2 3 4 5 6 Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or appli- cation, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applica- tions stated in the book. Every user is requested to ex- amine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules men- tioned therein or the contraindications stated by the manu- facturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly re- leased on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and re- sponsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccura- cies noticed. If errors in this work are found after publica- tion, errata will be posted at www.thieme.com on the pro- duct description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appear- ance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to pros- ecution. This applies in particular to photostat reproduc- tion, copying, mimeographing, preparation of microfilms, and electronic data processing and storage. Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. V Preface The present book, Differential Diagnosis in Internal Medicine, first appeared as a German edition in 1952 and since then has been translated into 10 other languages. Over the past 50 years 19 Ger- man editions have been published, and now the 19th edition of the work, which has become the classic differential diagnosis textbook, is available in English for the first time. This book encompasses differential diagnosis across the spectrum of internal medicine, cover- ing dermatology, neurology, and rheumatology, and provides the very latest knowledge including pathophysiological aspects. In contrast to ency- clopedically structured textbooks, this book traces the path from symptom to diagnosis, just as the physician encounters the situation in the hospital and in the office. With this pragmatic approach—starting from the symptom(s)—the physician will usually suc- ceed in substantiating the suspected diagnosis. Using this method, Siegenthaler’s Differential Di- agnosis in Internal Medicine guides the reader through the differential diagnostic challenges in the entire field of internal medicine, including dermatology, neurology, and rheumatology. The book incorporates many relevant and instructive illustrations, tables, graphics, and algorithms, all contributing to the process of narrowing down a definitive diagnosis. The book is intended for medical students, phy- sicians in clinical practice, generalists, and special- ists in internal medicine, dermatology, neurology, and rheumatology, and also for all those concerned with the fundamental subjects of medicine, who wish to gain a competent knowledge of internal medicine. My thanks are due to all of the colleagues who worked with me on the book, and also to Thieme Publishing Group, in particular Thieme Publishers Stuttgart. I hope that, with the launch of the Eng- lish edition, this classic textbook of differential di- agnosis in internal medicine will now also find its place in the English-speaking world. Walter Siegenthaler, MD Professor Emeritus of Internal Medicine University of Zürich Zürich, Switzerland Preface Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. VI Contributors Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. VII Foreword Foreword I first met Professor Walter Siegenthaler in the 1970s while he was at the University of Zürich, where both he and his late wife, the superb clini- cian Doctor Gertrud Siegenthaler-Zuber, were ad- mired for their many accomplishments and dedi- cation to the advancement of medicine. At that time, Professor Siegenthaler helped me establish a program to bring cardiologists from the Baylor College of Medicine and the Methodist Hospital in Houston, Texas, to Switzerland to study the pioneering balloon angioplasty work of Andreas Gruentzig. Subsequently, he honored us by serv- ing as a Visiting Professor at Baylor, exemplifying the best of Swiss medicine. Now, 30 years later, Professor Siegenthaler remains at the leading edge of medicine, as this expertly realized book in your hands attests. Differential diagnosis is the fundamental meth- odology of modern clinical medicine: we note the patient’s symptoms; we develop hypotheses for the affliction and propose treatment; and we ad- just treatment based on the patient’s response. Thus, differential diagnosis requires the physician to be observant, knowledgeable, thoughtful, thorough, and organized, qualities that could also be used to describe the conceptualization and ex- ecution of the following pages. In the last few de- cades, we have seen stunning advances in the level of clinical care and diagnostic procedures available across the spectrum of human diseases. The sophistication of contemporary nosology is truly impressive. On the other hand, the rapid turnover of medi- cal information can prove daunting to many clini- cians, and the application of the latest evidence to our daily interactions with patients may seem un- clear or too complex. Siegenthaler’s Differential Diagnosis in Internal Medicine reminds us to ap- proach diagnostic problems in a practical, system- atic, and critical manner, remembering that each patient’s circumstance is unique and that it is every doctor’s responsibility to exercise his or her best educated judgment to present rational choices about the most probable diagnoses and optimal treatment courses. Occam’s Razor, which advises us that the simplest explanation is usually the correct one, all things being equal, is an im- portant precept in diagnostic medicine, yet doc- tors must also be flexible and adaptable to the ec- centricities of every case. Thus, physicians should not expect to see a zebra when confronted with a horse, but they should be able to recognize the zebra on the rare occasion that it makes an ap- pearance. I believe that the scholarship, clinical skill, and practical wisdom that Professor Siegenthaler and his colleagues share with us in this text are indis- pensable resources for the medical community. The wealth of illustrative photographs, informa- tive tables, and up-to-date discussion of issues in internal medicine will prove very useful in daily clinical practice. Antonio M. Gotto, Jr., MD, DPhil The Stephen and Suzanne Weiss Dean Professor of Medicine Weill Cornell Medical College Provost for Medical Affairs Cornell University New York, USA Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. VIII Contributors Contributors Editor Prof. Dr. med. Dr. h. c. Walter Siegenthaler Forsterstr. 61 8044 Zürich, Switzerland Authors André Aeschlimann, MD Professor RehaClinic Zurzach Zurzach, Switzerland Esther Baechli, MD Spital Uster Medical Clinic Uster, Switzerland Claudio Bassetti, MD Professor University Hospital Zürich Clinic and Policlinic for Neurology Zürich, Switzerland Edouard Battegay, MD Professor University Hospital Basel Medical Policlinic Basel, Switzerland Manuel Battegay, MD Professor University Hospital Basel Department of Medicine Division of Infectiology Basel, Switzerland Peter Bauerfeind, MD Associate Professor University Hospital Zürich Departement of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Konrad Bloch, MD Professor University Hospital Zürich Department of Internal Medicine Division of Pneumology Zürich, Switzerland Hubert E. Blum, MD Professor and Director Department of Internal Medicine II University Medical Center Freiburg, Germany Thomas Bombeli, MD Associate Professor Research and Development Novo Nordisk S/A Bagsvaerd, Denmark Firat Duru, MD Professor University Hospital Zürich Department of Internal Medicine Division of Cardiology Cardiovascular Center Zürich, Switzerland Franz Eberli, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Cardiology Cardiovascular Center Zürich, Switzerland Joerg Fehr, MD Professor University Hospital Zürich Department of Internal Medicine Division of Hematology Zürich, Switzerland Thomas Fehr, MD Associate Professor Center for Nephrology University Hospital Zürich Zürich, Switzerland Adriano Fontana, MD Professor University Hospital Zürich Faculty of Medicine Department of Internal Medicine Division of Clinical Immunology Zürich, Switzerland Mark Fox, MD Research Consultant University Hospital Zürich Zürich, Switzerland Michael Fried, MD Professor University Hospital Zürich Department of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Peter Greminger, MD Professor St Gallen Canton Hospital Department of Internal Medicine St Gallen, Switzerland Klaus Hess, MD Professor University Hospital Zürich Clinic and Policlinic for Neurology Zürich, Switzerland Ulrich Hoffmann, MD Professor University of Munich Hospital Vascular Center—Angiology Munich, Germany Sabina Hunziker, MD University Hospital Basel Medical Policlinic Basel, Switzerland Dirk Jaeger, MD Associate Professor Director of Clinical Oncology National Center for Tumor Diseases Heidelberg, Germany Alexander Knuth, MD Professor University Hospital Zürich Clinic and Policlinic for Oncology Zürich, Switzerland Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. IX Marius Kraenzlin, MD Associate Professor Basel, Switzerland Hugo Kupferschmidt, MD Swiss Toxicology Information Center (STIZ) Zürich, Switzerland Stephan Lautenschlager, MD Associate Professor Dermatology Clinic Stadtspital Triemli Zürich, Switzerland Hans-Peter Marti, MD Professor University Hospital Zürich Department of Internal Medicine Division of Nephrology Zürich, Switzerland Benedict Martina, MD Associate Professor Basel University Hospital Medical Policlinic Basel, Switzerland Darius Moradpour, MD Professor Vaudois University Hospital Gastroenterology and Hepatology Service Lausanne, Switzerland Beat Muellhaupt, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Beat A. Michel, MD Professor University Hospital Zürich Rheumatism Clinic and Instititute of Physical Medicine Zürich, Switzerland Erwin Oechslin, MD Professor Director Congenital Cardiac Centre for Adults University Health Network Toronto, Canada Peter Ott, MD Professor University Hospital Zürich Otorhinolaryngology Policlinic Zürich, Switzerland Pietro Peghini, MD University Hospital Zürich Department of Internal Medicine Division of Hematology Zürich, Switzerland Erich W. Russi, MD Professor University Hospital Zürich Department of Internal Medicine Division of Pneumology Zürich, Switzerland Niklaus Schaefer, MD University Hospital Zürich Clinic and Policlinic for Oncology Zürich, Switzerland Urs Schanz, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Hematology Zürich, Switzerland Christoph Scharf, MD Associate Professor Klinik im Park Zürich, Switzerland Christoph Schmid, MD Professor University Hospital Zürich Department of Internal Medicine Division of Endocrinology and Diabetology Zürich, Switzerland Urs Schwarz, MD Associate Professor University Hospital Zürich Clinic and Policlinic for Neurology Zürich, Switzerland Werner Schwizer, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Giatgen A. Spinas, MD Professor University Hospital Zürich Department of Internal Medicine Division of Endocrinology and Diabetology Zürich, Switzerland S. Stoeckli, MD Associate Professor University Hospital Zürich Otorhinolaryngology Clinic Zürich, Switzerland Federico Tató, MD Associate Professor University of Munich Hospital Vascular Center—Angiology Munich, Germany Miriam Thumshirn, MD Associate Professor University Hospital Zürich Department of Internal Medicine Division of Gastroenterology and Hepatology Zürich, Switzerland Arnold von Eckardstein, MD Professor University Hospital Zürich Institute of Clinical Chemistry Zürich, Switzerland Rainer Weber, MD Professor University Hospital Zürich Department of Internal Medicine Division of Infectious Diseases and Hospital Hygiene Zürich, Switzerland Rudolf P. Wuethrich, MD Professor University Hospital Zürich Department of Internal Medicine Division of Nephrology Zürich, Switzerland Contributors Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. X Contents 1−3 General Differential Diagnosis 1 General Aspects of Diagnosis and Differential Diagnosis . . . . . . . . . . . . . . . . 2 M. Battegay, B. Martina, and E. Battegay 1.1 Elements of the Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Disease and Differential Diagnosis . . . . . . . . . . . . 4 Practical Procedure for Establishing a Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Correct Evaluation of Evident Findings and the Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . 6 How to Handle Errors in the Medical Field . . . . 9 Factors That Can Lead to False Diagnoses . . . . . 10 Physician-specific Problems . . . . . . . . . . . . . . . . . 10 Patient-specific Problems . . . . . . . . . . . . . . . . . . . 10 1.2 Factors That Can Influence the Differential Diagnostic Thought Process . . . . . . . . . . . . 11 Prevalence of Diseases . . . . . . . . . . . . . . . . . . . . . . . . 11 Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Eating Habits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Season, Time of Day, and Weather . . . . . . . . . . . . 14 Geographic Distribution . . . . . . . . . . . . . . . . . . . . . . 14 Ethnic Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Profession and Leisure . . . . . . . . . . . . . . . . . . . . . . . . 14 Precluding or Promoting Diseases . . . . . . . . . . . . 16 1.3 Differential Diagnosis by Groups of Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Degenerative Conditions . . . . . . . . . . . . . . . . . . . . . . 16 Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Immune Mediated Diseases . . . . . . . . . . . . . . . . . . . 17 Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Metabolic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Dysfunction of the Endocrine System . . . . . . . . . 20 Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Hereditary Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Chromosome Anomalies . . . . . . . . . . . . . . . . . . . . 21 Simple Mendelian Genetics . . . . . . . . . . . . . . . . . 21 Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Multifactorial Heredity . . . . . . . . . . . . . . . . . . . . . 22 Intoxications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2 History, Physical Examination, and Important Subjective Complaints . . 24 E. Battegay, S. Hunziker, and G.A. Spinas 2.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Greeting and Interview Setting . . . . . . . . . . . . . . . . 26 Components of the Clinical Interview . . . . . . . . . 26 2.2 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Thyroid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . 27 Chest and Lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Percussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Auscultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . 31 Neurological Examination . . . . . . . . . . . . . . . . . . . . 32 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. XI 2.3 The Asymptomatic Patient (Checkup) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Disease Prevention in Healthy Persons . . . . . . . . 33 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Screening and Differential Diagnosis in Apparently Healthy Persons . . . . . . . . . . . . . . . . . . 34 Periodic Health Exams . . . . . . . . . . . . . . . . . . . . . . 34 Case Finding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Hidden Agendas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 2.4 Important Subjective Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Appetite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Thirst/Polydipsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Definition of Diabetes Mellitus . . . . . . . . . . 38 Type 1 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . 39 Type 2 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . 39 Specific Types of Diabetes . . . . . . . . . . . . . . . 39 Gestational Diabetes . . . . . . . . . . . . . . . . . . . . 39 Complications of Diabetes Mellitus . . . . . . 40 Diabetes Insipidus . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Central Diabetes Insipidus . . . . . . . . . . . . . . . 40 Renal Diabetes Insipidus . . . . . . . . . . . . . . . . 40 Primary Polydipsia . . . . . . . . . . . . . . . . . . . . . . . . . 41 Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Hemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Palpitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Hiccups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 3 Skin and External Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 S. Lautenschlager, M. Battegay, and G.A. Spinas 3.1 Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Method of Examination . . . . . . . . . . . . . . . . . . . . . . . 53 Clinical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Skin Color . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Pallor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Redness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Discoloration . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Disturbances of Pigmentation . . . . . . . . . . . 54 Erythema and Exanthems . . . . . . . . . . . . . . . . . . 56 Vesicular Skin Diseases . . . . . . . . . . . . . . . . . . . . . 57 Bullous Skin Diseases . . . . . . . . . . . . . . . . . . . . . . . 59 Papular Skin Diseases . . . . . . . . . . . . . . . . . . . . . . 60 Plaque-forming Skin Diseases . . . . . . . . . . . . . . 60 Nodular Skin Diseases . . . . . . . . . . . . . . . . . . . . . . 60 Pustular Skin Diseases . . . . . . . . . . . . . . . . . . . . . . 61 Ulcerations of the Skin . . . . . . . . . . . . . . . . . . . . . 62 Urticarial Skin Diseases . . . . . . . . . . . . . . . . . . . . . 63 Purpura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Telangiectasias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Disturbances of Skin Turgor . . . . . . . . . . . . . . . . 64 Calcifications of the Skin . . . . . . . . . . . . . . . . . . . 64 Skin Changes Due to Systemic Disease . . . . . . . . 65 Skin Changes Due to Metabolic Disorders . . . . 65 Skin Changes Due to Endocrine Disorders . . . 66 Skin Changes Due to Tumors . . . . . . . . . . . . . . . . 66 Skin Changes Due to Collagenoses . . . . . . . . . . 67 Skin Changes as Adverse Effects of Medications and Intoxications . . . . . . . . . . . . . . 68 Skin Changes Due to Hematologic Diseases . . 68 Skin Changes Due to Gastrointestinal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Skin Changes Due to Hepatic Diseases . . . . . . . 69 Skin Changes Due to Heart Disease . . . . . . . . . . 69 Neurocutaneous Diseases . . . . . . . . . . . . . . . . . . . 69 Skin Changes Due to Infection . . . . . . . . . . . . . . 71 Hair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Hair Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Hirsutism and Virilism . . . . . . . . . . . . . . . . . . . . . 73 Pigmentation Disorders . . . . . . . . . . . . . . . . . . . . . 73 Nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Changes in Nail Shape and Structure . . . . . . . . 74 Nail Discoloration . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Oral Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Changes of the Teeth . . . . . . . . . . . . . . . . . . . . . . . 76 Changes of the Gums . . . . . . . . . . . . . . . . . . . . . . . 77 Changes of the Oral Mucosa . . . . . . . . . . . . . . . . 77 Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. XII 3.2 External Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Stature and Posture . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Tall Stature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Tall Stature Due to Congenital Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Tall Stature Due to Endocrine Disorders . . 80 Short Stature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Short Stature Due to Congenital Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Short Stature Due to Skeletal Dysplasias . 83 Short Stature Due to Chronic Diseases and Malabsorption Syndromes . . . . . . . . . . 83 Short Stature Due to Endocrine Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Standing Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Lying Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Primary Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Secondary Obesity . . . . . . . . . . . . . . . . . . . . . . . . . 87 Localized Collections of Fat and Lipody- strophies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Gynecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Anorexia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Hands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Exophthalmos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Horner Syndrome, Enophthalmos . . . . . . . . . . . 94 Eyebrows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Eyelids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Sclerae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Cornea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Iris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Pupil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Vitreous Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Retina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 The Red Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Ocular Motility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Ears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Odor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Language, Speech, and Phonation . . . . . . . . . . . . . 100 Disturbances of Language and Speech . . . . . . . 100 Disturbances of Phonation . . . . . . . . . . . . . . . . . . 102 4 Fever 4 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 R. Weber and A. Fontana 4.1 General Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Medical History and Clinical Findings . . . . . . . . . 111 Differential Diagnostic Considerations . . . . . . . . 111 Fever of Unknown Origin . . . . . . . . . . . . . . . . . . . . . 113 4.2 Fever without Localized Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Noninfectious Causes . . . . . . . . . . . . . . . . . . . . . . . . . 115 Hospitalized Patients . . . . . . . . . . . . . . . . . . . . . . . . . 116 4.3 Fever with Associated Cardinal Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Fever and Skin Rashes . . . . . . . . . . . . . . . . . . . . . . . . 116 Petechiae and Purpura . . . . . . . . . . . . . . . . . . . . . 116 Maculopapular Exanthema . . . . . . . . . . . . . . . . . 118 Vesicles and Pustules . . . . . . . . . . . . . . . . . . . . . . . 118 Nodular Skin Lesions . . . . . . . . . . . . . . . . . . . . . . . 118 Erythema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Urticaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Bacterial Skin Infections . . . . . . . . . . . . . . . . . . . . 119 Mycobacterial Skin Infections . . . . . . . . . . . . . . . 120 Rickettsial Diseases . . . . . . . . . . . . . . . . . . . . . . . . 121 Viral Diseases with Skin Rashes . . . . . . . . . . . . . 122 Fever and Joint or Bone Pain . . . . . . . . . . . . . . . . . . 125 Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Osteomyelitis, Spondylodiscitis, and Joint Prostheses Infections . . . . . . . . . . . . . . . . . . . . . . . 126 Fever and Lymph Node Enlargement . . . . . . . . . . 127 Fever and Generalized Lymph Node Enlargement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Fever and Localized Lymph Node Enlargement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Infections of the Lymph Nodes . . . . . . . . . . . . . . 128 Lymphadenopathy of Unknown Origin . . . . . . 129 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. XIII Fever and Swelling of the Face or Neck . . . . . . . 130 Parotid Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Neck Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Fever, Headaches, and Neck Stiffness . . . . . . . . . . 131 Examination of the Cerebrospinal Fluid (CSF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Bacterial Meningitis . . . . . . . . . . . . . . . . . . . . . . . . 133 Serous Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Fungal Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Meningitis Caused by Protozoa or Helminths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Concomitant Cases of Meningitis . . . . . . . . . . . . 135 Fever and Neurological Deficits . . . . . . . . . . . . . . . 136 Encephalitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Cerebral Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Subdural Empyema, Epidural Abscess . . . . . . . 138 Fever with Common Cold Symptoms . . . . . . . . . . 138 Bacterial Tonsillitis and Pharyngitis . . . . . . . . . 138 Nonbacterial Pharyngitis . . . . . . . . . . . . . . . . . . . 138 Common Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Otitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Epiglottitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Fever, Cough, and Thoracic Pain . . . . . . . . . . . . . . 141 Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Nontuberculous Mycobacterioses . . . . . . . . . . . 144 Nocardiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Pericarditis, Myocarditis . . . . . . . . . . . . . . . . . . . . 145 Noninfectious Diseases . . . . . . . . . . . . . . . . . . . . . 145 Fever and Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Prehepatic Jaundice . . . . . . . . . . . . . . . . . . . . . . . . 145 Hepatic Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Posthepatic Jaundice . . . . . . . . . . . . . . . . . . . . . . . 147 Fever and Splenomegaly . . . . . . . . . . . . . . . . . . . . . . 146 Fever and Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Intestinal Infections . . . . . . . . . . . . . . . . . . . . . . . . 147 Pathogens Causing Diarrhea . . . . . . . . . . . . . . . . 148 Fever and Abdominal Pain . . . . . . . . . . . . . . . . . . . . 149 Intra-abdominal Infections . . . . . . . . . . . . . . . . . 149 Peritonitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Intra-abdominal Abscesses . . . . . . . . . . . . . . . . . 150 Visceral Abscesses . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Specific Causes of Intra-abdominal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Fever, Dysuria, and Pollakisuria . . . . . . . . . . . . . . . 151 Urethritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Acute Uncomplicated Urinary Tract Infections in Women . . . . . . . . . . . . . . . . . . . . . . . 151 Acute Uncomplicated Pyelonephritis . . . . . . . . 151 Acute Complicated Pyelonephritis . . . . . . . . . . . 152 Prostatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Fever and Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Systemic Inflammatory Response Syndrome (SIRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Bacteremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Sources of Sepsis, Predisposition . . . . . . . . . . . . 153 Selected Sepsis Pathogens . . . . . . . . . . . . . . . . . . 153 Fever and Heart Defects . . . . . . . . . . . . . . . . . . . . . . 155 Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Other Endovascular Infections . . . . . . . . . . . . . . 156 4.4 Fever with Multiple Organ Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Viral Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Cytomegalovirus Infection . . . . . . . . . . . . . . . . . . 157 Tickborne Infections . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Lyme Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Ehrlichiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Babesiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Sexually Transmitted Infections . . . . . . . . . . . . . . . 159 Syphilis (Treponema pallidum) . . . . . . . . . . . . . . 159 Chlamydia trachomatis . . . . . . . . . . . . . . . . . . . . . 161 Zoonosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Brucellosis (Brucella melitensis, B. abortus, B. suis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Leptospirosis (Leptospira interrogans [Weil disease] and other serotypes) . . . . . . . . . . . . . . . 162 Toxoplasmosis (Toxoplasma gondii) . . . . . . . . . 162 Trichinosis (Trichinella spiralis) . . . . . . . . . . . . . . 162 Toxocara Infection . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Rabies (Rhabdoviruses) . . . . . . . . . . . . . . . . . . . . . 163 Other Infections Caused by Animal Bites . . . . . 163 Infections by Arboviruses . . . . . . . . . . . . . . . . . . . 163 HIV Infection and AIDS . . . . . . . . . . . . . . . . . . . . . . . 163 Acute HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . 163 Asymptomatic HIV Infection . . . . . . . . . . . . . . . . 164 Symptomatic HIV Infection, AIDS . . . . . . . . . . . 164 Infections in Immunocompromised Persons . . 167 Opportunistic Viral Infections . . . . . . . . . . . . . . . 168 Opportunistic Bacterial Infections . . . . . . . . . . . 168 Opportunistic Fungal Infections . . . . . . . . . . . . . 168 Opportunistic Protozoa and Helminths . . . . . . 169 Mycoses in Localized Endemic Regions . . . . . . . . 170 Coccidioidomycosis (Coccidioides immitis) . . . 170 Histoplasmosis (Histoplasma capsulatum) . . . . 171 Travel and Tropical Diseases . . . . . . . . . . . . . . . . . . 170 Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Leishmaniasis (Leishmania donovani) . . . . . . . . 172 Schistosomiasis (Bilharziosis) . . . . . . . . . . . . . . . 173 Lymphatic Filariasis . . . . . . . . . . . . . . . . . . . . . . . . 174 Tissue Filariases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Dengue Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Yellow Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Other Tropical Diseases . . . . . . . . . . . . . . . . . . . . . 175 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license. XIV 4.5 Fever in Autoimmune Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Localized or Organ-Specific Autoimmune Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Generalized Autoimmune Disease, Vasculitis, and Connective Tissue Syndrome . . . . . . . . . . . . . 176 Vasculitis of Large Vessels . . . . . . . . . . . . . . . . . . . . 178 Giant Cell Arteritis (Arteritis Temporalis Horton) and Polymyalgia Rheumatica Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Vasculitis of Medium-Sized Vessels . . . . . . . . . . . 178 Polyarteritis Nodosa or Panarteritis . . . . . . . . . 178 Vasculitis of Small Vessels . . . . . . . . . . . . . . . . . . . . 180 Wegener Granulomatosis . . . . . . . . . . . . . . . . . . . 180 Allergic Granulomatosis (Churg−Strauss Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Hypersensitivity Vasculitis . . . . . . . . . . . . . . . . . . 181 Purpura−Arthralgia−Nephritis Syndrome . . . . 181 Systemic Lupus Erythematosus (SLE) . . . . . . . . 181 Scleroderma (Progressive Diffuse or Generalized Scleroderma or Progressive Systemic Sclerosis [PSS]) . . . . . . . . . . . . . . . . . . . 183 Circumscribed Scleroderma . . . . . . . . . . . . . . . . . 184 Scleroederma Adultorum (Buschke Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Eosinophilic Fasciitis (Shulman Syndrome) . . 186 Sharp Syndrome, Overlap Syndrome (Mixed Connective Tissue Disease [MCTD]) . . 186 Dermatomyositis (Polymyositis) . . . . . . . . . . . . 186 4.6 Fever in Immune Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Classification of Immune Deficiency . . . . . . . . . . 187 Humoral Immune Deficiencies (B-cell Deficiencies) . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Cellular Immune Deficiencies (T cell Deficiencies) . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Combined Humoral and Cellular Immune Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Defects of the Complement System . . . . . . . . . . . 191 Defects of Phagocytosis . . . . . . . . . . . . . . . . . . . . . . 191 4.7 Fever in Various Noninfectious Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Periodic Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Familial Mediterranean Fever . . . . . . . . . . . . . . . 192 Hyper-IgD Syndrome . . . . . . . . . . . . . . . . . . . . . . . 192 Tumor Necrosis Factor Receptor-associated Periodic Fever Syndrome (TRAPS) . . . . . . . . . . . 193 “PFAPA” Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . 193 Fever in Endocrine Disorders . . . . . . . . . . . . . . . . . 193 Fever in Vegetative Dystonia . . . . . . . . . . . . . . . . . . 193 Chronic Mercury Intoxication . . . . . . . . . . . . . . . . . 193 Chronic Fatigue Syndrome . . . . . . . . . . . . . . . . . . . . 193 Fever in Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Fever in Tissue Degradation . . . . . . . . . . . . . . . . . . . 194 Fever in Hemolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Hemophagocytosis Syndrome . . . . . . . . . . . . . . . . . 195 Fever in Thrombosis and Thrombophlebitis . . . 195 Fever in Allergic Reactions . . . . . . . . . . . . . . . . . . . . 195 Simulated Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 4.8 Significance of Individual Findings for the Differentiation of Febrile States . . . . . . . . . 195 Course of the Temperature . . . . . . . . . . . . . . . . . . . 195 Chills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Inflammation Parameters . . . . . . . . . . . . . . . . . . . . 196 Erythrocyte Sedimentation Rate (ESR) . . . . . . . 196 C-reactive Protein (CRP) . . . . . . . . . . . . . . . . . . . . 197 Procalcitonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Blood Count . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Leukocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Eosinophils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Monocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Lymphocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Contents Siegenthaler, Differential Diagnosis in Internal Medicine, © 2007 Thieme All rights reserved. Usage subject to terms and conditions of license.

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