Clinical and radiographic clues to the etiology of pneumonia in children*

Etiology	Clinical features	Radiographic features
Bacteria (most commonly Streptococcus pneumoniae)	Children of all ages Abrupt onset Ill-appearance Chills Moderate to severe respiratory distress Focal auscultatory findings Localized chest pain WBC count >15,000/microL (if obtained) Elevated acute phase reactants (if obtained)	Alveolar infiltrates Segmental consolidation Lobar consolidation "Round" pneumonia Complications: Pleural effusion/empyema Lung abscess Necrotizing pneumonia Pneumatocele
Atypical bacterial (Mycoplasma pneumoniae, Chlamydia pneumoniae)	Children of all ages (most common in children >5 years) Abrupt onset with constitutional findings (malaise, myalgia, headache, rash, conjunctivitis, photophobia, sore throat) Gradually worsening nonproductive cough Wheezing Extrapulmonary manifestations or complications (eg, polymorphous mucocutaneous eruptions, hemolytic anemia, hepatitis, pancreatitis, myopericarditis, aseptic meningitis)	M. pneumoniae: Lobar or segmental consolidation (37%) Parahilar or peribronchial infiltrates (27%) Localized reticulonodular infiltrates (21%) Patchy infiltrates (15%)
Viral	Usually children <5 years Gradual onset Preceding upper airway symptoms Nontoxic appearing Diffuse, bilateral auscultatory findings Wheezing May have associated rash (eg, measles, varicella)	Interstitial infiltrates Associated bronchiolitis: Patchy atelectasis Peribronchial infiltrations with air bronchograms Hyperinflation with flattening of the diaphragms
Afebrile pneumonia of infancy (most commonly Chlamydia trachomatis)	Usually in infants 2 weeks to 4 months Insidious onset Tachypnea, diffuse crackles Rhinorrhea Staccato cough pattern Peripheral eosinophilia (if CBC obtained)	Hyperinflation with interstitial infiltrates
Fungal	Appropriate geographic or environmental exposure	Mediastinal or hilar adenopathy
Mycobacterium tuberculosis	Children of any age Chronic cough Constitutional symptoms Exposure history	Mediastinal or hilar adenopathy

WBC: white blood cell; CBC: complete blood count.

* The clinical features frequently overlap and cannot reliably distinguish between bacterial, atypical bacterial, and viral etiologies; up to one-half of community-acquired pneumonias in children may be mixed bacterial/viral infections. Chest radiography generally is not helpful in determining the potential causative agent of pneumonia. Nonetheless, these features may facilitate decisions regarding empiric therapy.

Data from:

Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med 1995; 333:1618.
Boyer KM. Nonbacterial pneumonia. In: Textbook of Pediatric Infectious Diseases, 6^th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. p.289.
Broughton RA. Infections due to Mycoplasma pneumoniae in childhood. Pediatr Infect Dis 1986; 5:71.
McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
Cho YJ, Han MS, Kim WS, et al. Correlation between chest radiographic findings and clinical features in hospitalized children with Mycoplasma pneumoniae pneumonia. PLoS One 2019; 14:e0219463.
Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health 1990; 26:209.

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Clinical and radiographic clues to the etiology of pneumonia in children*