Viral Pneumonia Differential Diagnoses

  • Author: Zab Mosenifar, MD; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: May 26, 2011
 
 

Diagnostic Considerations

Studies show that patients are frequently infected with both bacterial and viral pathogens, making it impossible to rule out bacterial disease even when rapid viral test results are positive. Additionally, no unique identifying clinical characteristics are present that allow the physician to differentiate viral disease from bacterial disease in the emergency department (ED).

Although the most common cause of community-acquired pneumonia remains Streptococcus pneumoniae (a fact that may change with the increasing use of pneumococcal vaccines), in as many as 40-60% of patients with community-acquired pneumonia, the etiologic agent is not identified. Furthermore, convincing associations between the patient's symptoms, physical findings, laboratory test results, and specific etiologies are lacking.

Therefore, no way of accurately determining the etiology of pneumonia during the initial visit to the ED exists. Obtaining a chest radiograph in patients with suspected pneumonia is recommended, both to find complications, such as pleural effusions, and to discourage the use of antibiotics in healthy patients with bronchitis rather than pneumonia.

Influenza viruses are the most common cause of viral pneumonia in civilian adults. Influenza usually is seen in epidemics and pandemics. Influenza A is the serotype most frequently responsible for major epidemics and pandemics; it is the most frequent cause of viral pneumonia in adults.

Influenza epidemics occur during the winter months and are associated with significant morbidity and mortality. Patients with chronic obstructive pulmonary disease (COPD), heart failure, hemoglobinopathies, and immunosuppression are at increased risk for severe disease, which can lead to death. Influenza virus is transmitted from person to person primarily by droplet and aerosol exposure to the virus. The incubation period is 1-5 days after exposure.

Patients with high-grade fever, myalgias, and cough during the winter months should be suspected to have influenza. If test results are negative for influenza, RSV pneumonia should also be suspected during the winter in patients with coryza, wheezing, low-grade fever, and patchy infiltrates on chest radiographs. Because clinical features and periods of activity for many viruses overlap, laboratory confirmation of influenza is recommended for cases involving patients who are seriously ill or institutionalized.

Viral pathogens and host factors

Patient age and immune status can offer a clue to the possible etiology of viral pneumonia. The following viruses commonly cause pneumonia in children:

  • Respiratory syncytial virus
  • Influenza viruses A and B
  • Parainfluenza virus
  • Adenovirus
  • Human metapneumovirus
  • Coronavirus
  • Measles virus (in unvaccinated children)

The following viruses commonly cause pneumonia in immunocompetent adults:

  • Influenza viruses A and B
  • Adenovirus
  • Respiratory syncytial virus
  • Parainfluenza virus
  • Coronavirus
  • Varicella-zoster virus

The following viruses commonly cause pneumonia in immunocompromised hosts:

  • Cytomegalovirus
  • Herpes simplex virus
  • Influenza
  • Respiratory syncytial virus
  • Parainfluenza virus
  • Adenovirus
  • Varicella-zoster virus

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Shakeel Amanullah, MD  Consulting Physician, Pulmonary, Critical Care, and Sleep Medicine, Lancaster General Hospital

Shakeel Amanullah, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Michael S Beeson, MD, MBA, FACEP  Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Paul Blackburn, DO, FACOEP, FACEP  Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

Dan V Dinescu, MD  Fellow in Pulmonary Medicine, Department of Internal Medicine, Memorial Sloan Kettering Cancer Center

Dan V Dinescu, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Thoracic Society, Medical Society of the State of New York, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Arthur Jeng, MD  Assistant Professor of Clinical Medicine, University of California at Los Angeles School of Medicine

Arthur Jeng, MD is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Nader Kamangar, MD, FACP, FCCP, FCCM  Associate Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, Los Angeles, David Geffen School of Medicine, Olive View-UCLA Medical Center; Associate Program Director, Pulmonary and Critical Care Multi-Campus Fellowship Program, Cedars-Sinai/West Los Angeles Veterans Affairs/Los Angeles Kaiser Permanente/Olive View-UCLA Medical Center; Site Director, Pulmonary/Critical Care Fellowship Program, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: American Academy of Sleep Medicine, American Association of Bronchology, American College of Chest Physicians, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Gloria J Kuhn, DO, PhD, FACEP  Professor, Vice-Chair of Academic Affairs, Dept of Emergency Medicine, Wayne State University School of Medicine; Professor, Department of Internal Medicine, Section of Emergency Medicine, Michigan State University College of Osteopathic Medicine

Gloria J Kuhn, DO, PhD, FACEP is a member of the following medical societies: American Osteopathic Association

Disclosure: Nothing to disclose.

Mark L Shapiro, MD  Chief, Department of Radiology, Englewood Hospital and Medical Center

Mark L Shapiro, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

Satinder P Singh, MD, FCCP  Professor of Radiology and Medicine, Chief of Cardiopulmonary Radiology, Director of Cardiac CT, Director of Combined Cardiopulmonary and Abdominal Radiology, Department of Radiology, University of Alabama at Birmingham School of Medicine

Disclosure: Nothing to disclose.

Eric J Stern, MD  Professor of Radiology, Adjunct Professor of Medicine, Adjunct Professor of Medical Education and Biomedical Informatics, Adjunct Professor of Global Health, Vice-Chair, Academic Affairs, University of Washington School of Medicine

Eric J Stern, MD is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, European Society of Radiology, Radiological Society of North America, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark R Wallace, MD, FACP, FIDSA  Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Kavita Garg, MD  Professor, Department of Radiology, University of Colorado School of Medicine

Kavita Garg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Sat Sharma, MD, FRCPC, to the development and writing of the source articles.

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Pneumonia, viral: A 52-year-old woman developed fever, cough, and dyspnea. She also developed a rash that was prominent over the face and the trunk. The chest radiograph showed interstitial infiltrates, with suggestion of a micronodular process. The Tzanck smear results from the skin vesicle suggest varicella-zoster virus.
Pneumonia, viral: A 52-year-old woman developed fever, cough, and dyspnea. She also developed a rash that was prominent over the face and the trunk. The chest radiograph showed interstitial infiltrates, with suggestion of a micronodular process. The Tzanck smear results from the skin vesicle suggest varicella-zoster virus. She was treated with acyclovir; resolution of varicella-zoster virus infection occurred after 7 days of therapy.
Bilateral interstitial infiltrates in a 31-year-old patient with influenza pneumonia.
Table 1. Diagnostic Techniques Used for Viral Pneumonia
Virus Viral Culture Cytologic Evaluation Rapid Antigen Detection Gene Amplification
Influenza virusHA*, SV†IF‡, ELISA§RT-PCR#
AdenovirusCE, SVIntranuclear inclusionsIF, ELISART-PCR
Paramyxoviruses
Respiratory syncytial virusCE, SVEosinophilic cytoplasmic inclusionsIF, ELISART-PCR
Parainfluenza virusHA, SVEosinophilic intranuclear inclusionsIF, ELISART-PCR
Measles virusHA
Herpes viruses
Herpes simplex virusCE, SVCytoplasmic inclusionsIF, ELISAPCR
Varicella-zoster virusCECytoplasmic inclusionsIFRT-PCR
CytomegalovirusCE, SV"Owl's eye" cellsIF, ELISART-PCR
HantavirusAntibodies against FCV**FVC RNA by RT-PCR
* HA - Hemaglutination



† SV - Shell viral culture



‡ IF - Immunofluorescence



§ ELISA - Enzyme-linked immunosorbent assay



CE - Cytopathogenic effects



# RT-PCR - Reverse transcriptase polymerase chain reaction



** FCV - Four corners virus



Table 2. Treatment and Prevention of Common Causes of Viral Pneumonia
Virus Treatment Prevention
Influenza virusAmantadine



Rimantadine



Influenza vaccine



Chemoprophylaxis with:



Amantadine



Rimantadine



Zanamivir



Oseltamivir



Respiratory syncytial virusRibavirinRSV immunoglobulin



Palivizumab



Parainfluenza virusRibavirin
Herpes simplex virusAcyclovir
Varicella-zoster virusAcyclovirVaricella-zoster immunoglobulin
AdenovirusRibavirin
Measles virusRibavirinIntravenous immunoglobulin
CytomegalovirusGanciclovir



Foscarnet



Intravenous immunoglobulin
Table 3. Characteristics of Anti-Influenza Drugs
Amantadine



(Symmetrel)



Rimantadine



(Flumadine)



Zanamivir



(Relenza)



Oseltamivir



(Tamiflu)



Mechanism of actionM2 ion channel blockade inhibits HA* cleavage beta block RNA encoding, which reduces early viral replication.Viral NA† inhibition prevents sialic acid cleavage from HA beta virus gets trapped inside cells, and epithelial spread is blocked.
SpectrumInfluenza A onlyInfluenza A onlyInfluenza A and BInfluenza A and B
Oral bioavailabilityGoodGoodPoorGood
Protein binding, %6740NoneMinimal
Half-life, h12-1824-362.5-51-3
ExcretionRenal (not removed by hemodialysis)Renal and gastrointestinalRenal
Drug interactionSynergistic CNS toxicity with antihistamines, anticholinergics, CNS stimulantsBeta Plasma level: ASA§, acetaminophenNoneNone
Renal clearanceTMP-SMZ, triamterene, hydrochlorothiazide, quinine sulfate, quinidineCimetidineNoneNone
* HA - Hemagglutinin



† NA - Neuraminidase



§ ASA - Acetylsalicylic acid



TMP-SMZ - Trimethoprim and sulfamethoxazole



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