Diagnostic Considerations

Pneumonia can occur at any age, although it is more common in younger children. Different age groups tend to be infected by different pathogens, which affects diagnostic and therapeutic decisions.

Many patients referred for evaluation for recurrent pneumonia are diagnosed with asthma. In emergency department studies, 35% of children with an asthma exacerbation have abnormalities visible on chest radiographs. In a child not yet diagnosed with asthma, these abnormalities are frequently interpreted simply as pneumonia. Inflammation, often triggered by viral infection, is part of the asthmatic response. Wheezing responsive to bronchodilators, a history of atopy, a family history of asthma, and a history of cough or wheeze with exercise may be helpful in identifying such patients.

Consider any other diseases that may present with respiratory dysfunction in the first 24 hours of life. Keep in mind that any of the conditions listed below may also be superimposed by pneumonia:

Alveolar-capillary dysplasia
Arrhythmia
Asphyxia
Bronchial duplication
Chest wall injury or anomaly
Choanal atresia
Chylothorax
Diaphragmatic eventration
Heart block
Intracranial hemorrhage
Laryngeal cleft
Laryngeal nerve injury
Mutation of ABCA3 gene (for surfactant phospholipid transport)
Neuromuscular disorders
Phrenic nerve injury
Pulmonary hemorrhage
Pulmonary hypoplasia
Pulmonary lymphangiectasia
Spinal injury
Surfactant-related protein B deficiency
Tachycardia syndromes
Tracheoesophageal fistula
Transplacental medications
Vascular catheter accident
Other causes of airway obstruction
Other congenital heart diseases
Other inborn errors of metabolism
Other neuromuscular diseases

A careful history and examination in patients with recurrent pneumonia are both very helpful to further narrow the differential diagnosis. However, additional testing is often needed to confirm most of these diagnoses and is generally outside the scope of a primary care provider.

Differential Diagnoses

Acidosis, Metabolic
Acute Anemia
Acute Hypoglycemia
Afebrile Pneumonia Syndrome
Agammaglobulinemia
Alveolar Proteinosis
Aortic Stenosis
Aortic Stenosis, Subaortic
Aortic Stenosis, Valvar
Aseptic Meningitis
Asphyxiating Thoracic Dystrophy (Jeune Syndrome)
Aspiration Syndromes
Asthma
Atelectasis, Pulmonary
Atrioventricular Septal Defect, Complete
Atrioventricular Septal Defect, Unbalanced
Bacteremia
Birth Trauma
Bowel Obstruction in the Newborn
Bronchiectasis
Bronchiolitis
Bronchitis
Bronchitis, Acute and Chronic
Bronchogenic Cyst
Cardiomyopathy, Hypertrophic
Chronic Anemia
Chronic Granulomatous Disease
Coarctation of the Aorta
Coccidioidomycosis and Valley Fever
Severe Combined Immunodeficiency (SCID)
Common Variable Immunodeficiency
Complement Deficiency
Complement Receptor Deficiency
Congenital Diaphragmatic Hernia
Congenital Pneumonia
Congenital Stridor
Cystic Adenomatoid Malformation
Cystic Fibrosis
Double Outlet Right Ventricle, Normally Related Great Arteries
Double Outlet Right Ventricle, With Transposition
Ebstein Anomaly
Emergent Management of Atrial Flutter
Empyema
Esophageal Atresia With or Without Tracheoesophageal Fistula
Foreign Body Aspiration
Gastroesophageal Reflux
Goodpasture Syndrome
Head Trauma
Hemosiderosis
Hemothorax
Human Immunodeficiency Virus Infection
Hypersensitivity Pneumonitis
Hypocalcemia
Hypoplastic Left Heart Syndrome
IgA and IgG Subclass Deficiencies
Inhalation Injury
Interrupted Aortic Arch
Legionella Infection
Meningitis, Bacterial
Neural Tube Defects
Patent Ductus Arteriosus (PDA)
Pediatric Acute Respiratory Distress Syndrome
Pediatric Airway Foreign Body
Pediatric Histoplasmosis
Pediatric Pleural Effusion
Pediatric Pneumococcal Infections
Pediatric Pulmonary Hypoplasia
Pertussis
Pneumococcal Infections
Pneumonia, Aspiration
Pneumonia, Bacterial
Pneumonia, Empyema and Abscess
Pneumonia, Immunocompromised
Pneumonia, Mycoplasma
Pneumothorax
Pulmonary Atresia With Intact Ventricular Septum
Pulmonary Atresia With Ventricular Septal Defect
Pulmonary Hypertension, Persistent-Newborn
Pulmonary Sequestration
Q Fever
Respiratory Distress Syndrome
Respiratory Distress Syndrome
Smoke Inhalation Injury
Total Anomalous Pulmonary Venous Connection
Transient Tachypnea of the Newborn
Transposition of the Great Arteries
Tricuspid Atresia
Truncus Arteriosus
Vascular Ring, Double Aortic Arch
Vascular Ring, Right Aortic Arch

Workup

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Media Gallery

(Left) Gram stain demonstrating gram-positive cocci in pairs and chains and (right) culture positive for Streptococcus pneumoniae.
A breakdown of test results and recommended treatment for pneumonia with effusion. Gm = Gram; neg = negative; pos = positive; VATS = video-assisted thoracic surgery
(A) Anteroposterior radiograph from a child with presumptive viral pneumonia. (B) Lateral radiograph of the same child with presumptive viral pneumonia.
Radiograph from a patient with bacterial pneumonia (same patient as in the preceding image) a few days later. This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic pleural effusion.
Right lower lobe consolidation in a patient with bacterial pneumonia.
(A) Anteroposterior radiograph from a child with a left lower lobe infiltrate. (B) Lateral radiograph of the same child with a left lower lobe infiltrate.
Anteroposterior radiograph from a child with a round pneumonia.

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Author

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA Professor of Emergency Medicine and Clinical Pediatrics, Weill Cornell Medical College; Attending Physician, Departments of Emergency Medicine and Pediatrics, Lincoln Medical and Mental Health Center; Adjunct Professor of Emergency Medicine, Adjunct Professor of Pediatrics, St George's University School of Medicine, Grenada

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Academy of Urgent Care Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, Association of Clinical Research Professionals, Public Responsibility in Medicine and Research, Society for Academic Emergency Medicine, Society for Simulation in Healthcare

Disclosure: Nothing to disclose.

Coauthor(s)

Marie-Micheline Lominy, MD Attending Physician, Lincoln Medical Center; Physician in Pediatric Adolescent Medicine, Boston Children's Health Physicians

Marie-Micheline Lominy, MD is a member of the following medical societies: American Academy of Pediatrics, Haitian Medical Association Abroad, Haiti Red Cross Society

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics, Novavax, Regeneron, Diassess, Actelion<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur.

Nicholas John Bennett, MBBCh, PhD, FAAP, MA(Cantab) Assistant Professor of Pediatrics, Co-Director of Antimicrobial Stewardship, Medical Director, Division of Pediatric Infectious Diseases and Immunology, Connecticut Children's Medical Center

Nicholas John Bennett, MBBCh, PhD, FAAP, MA(Cantab) is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics

Disclosure: Received research grant from: Cubist<br/>Received income in an amount equal to or greater than $250 from: Horizon Pharmaceuticals, Shire<br/>Medico legal consulting for: Various.

Acknowledgements

Leslie L Barton, MD Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society