Differential Diagnosis of Vertigo with Fever and Cough

Immediate Life-Threatening Considerations

• The American Academy of Otolaryngology-Head and Neck Surgery recommends excluding posterior circulation stroke first, looking for dysarthria, dysphagia, visual blurring, drop attacks, or limb weakness/numbness, which distinguish stroke from peripheral vestibular causes 1, 3
• Vertigo lasting minutes with severe imbalance, nausea, and vomiting without hearing loss suggests ischemia, which is permanent and non-fluctuating 1
• Red flags requiring emergency imaging include direction-changing nystagmus without head position changes, downbeating nystagmus, severe imbalance disproportionate to vertigo, or any focal neurological deficits 3

Primary Differential Based on Symptom Constellation

• Viral or bacterial infection can lead to complete hearing loss and vestibular crisis with prolonged vertigo 1
• Vestibular neuritis causes acute prolonged vertigo with severe rotational vertigo, nausea, and vomiting without hearing loss, tinnitus, or aural fullness 1, 2

Less Likely but Important Differentials

• Multiple sclerosis can present with progressive fluctuating bilateral hearing loss that is steroid-responsive, along with vision, skin, and joint problems 1
• Vestibular migraine presents with attacks lasting hours with more photophobia than visual aura, and hearing loss is less likely than in Ménière's disease 1

Critical Diagnostic Algorithm

• The American Academy of Otolaryngology-Head and Neck Surgery suggests performing a targeted neurological examination for dysarthria, dysphagia, visual disturbances, motor/sensory deficits, or Horner's syndrome 3
• Emergency neuroimaging is required if any red flags are present, such as direction-changing nystagmus, downbeating nystagmus, or baseline nystagmus without provocative maneuvers 3
• The duration of vertigo can help differentiate between conditions, with seconds suggesting BPPV, minutes suggesting stroke/TIA, hours suggesting Ménière's/migraine, and >24 hours suggesting labyrinthitis/neuritis 1, 2, 5

Common Pitfalls to Avoid

• Do not dismiss neurological symptoms as anxiety when vertigo is accompanied by fever and respiratory symptoms 3
• Do not overlook subtle neurological signs in the presence of obvious vestibular symptoms; always check for dysarthria, dysphagia, and visual changes 3
• Do not delay imaging if vertigo persists >24 hours without improvement or if any central features are present 2, 3