History

Mycoplasmal pneumonia is a disease of gradual and insidious onset of several days to weeks. A recent Cochrane Review determined that M pneumoniae cannot be reliably diagnosed in children and adolescents with community-acquired pneumonia based on clinical signs and symptoms.^[21]The patient's history may include the following:

Fever, generally low-grade
Malaise
Persistent, slowly worsening, incessant cough. The cough ranges from non-productive to mildly productive with sputum discoloration developing late in the course of the illness. The absence of cough makes the diagnosis of M pneumoniae unlikely.^[22]
Headache
Chills but not rigors
Scratchy sore throat
Sore chest and tracheal tenderness (result of the protracted cough)
Pleuritic chest pain (rare)
Wheezing
Dyspnea (uncommon)

A model that integrated age, sex, season, infiltration scope, radiological patterns, and history of allergy showed good efficacy in predicting wheezing attacks in children with mycoplasmal pneumonia.^[23]

Physical Examination

Most cases of pneumonia due to M pneumoniae resolve after several weeks, although a dry cough can be present for as long as a month. Some patients can have a protracted illness lasting as long as six weeks. Other findings may also include the following:

A nontoxic general appearance
Mild pharyngeal injection with minimal or no cervical adenopathy but no exudate
Normal lung findings with early infection but rhonchi, rales, and/or wheezes several days later
Various exanthems including erythema multiforme and Stevens-Johnson syndrome
Sinus tenderness may be present

M pneumoniae has long been associated with bullous myringitis, but this has been largely disproven. Bullous myringitis is defined as the appearance of vesicles or bulla on the tympanic membrane. Several studies and extensive reviews have refuted the claim that bullous myringitis is pathognomonic for M pneumoniae.^{[24, 25]}In fact, M pneumoniae is rarely cultured from bullae on the tympanic membrane. Common middle ear pathogens in the clinical presentation of otitis media are much more commonly associated with tympanic membrane bullae.^{[26, 27, 28, 29]}

Differential Diagnoses

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