Mycoplasma pneumoniae, a small, cell walldefcient bacterium, is an important and treatable cause of community-

acquired, atypical pneumonia in children . 6The M pneumoniae organism is pleomorphic and demonstrates variable
clinical and radiographic fndings. At microscopic analysis, these organisms assume variable forms that can resemble
fungal flaments. The lack of a cell wall makes them insensitive to the usual antibiotics that are used to treat other
common pneumonias; therefore, diferentiation from bacterial pulmonary infections is vital to successful treatment.
Mycoplasma pneumonia can mimic viral respiratory tract infections both clinically and radiographically; unlike viruses,
however, mycoplasma infection is treatable. Appropriate antibiotic therapy for mycoplasma infections (usually with
erythromycin, azithromycin, or tetracycline) can help prevent the spread of the infection to contacts and limit the
course of the disease in the patient. Prompt therapy may also help avert extrarespiratory manifestations of
mycoplasma pneumonia, which can occasionally be severe.
Focal reticulonodular patterns in four diferent patients. (a) Posteroanterior radiograph demonstrates a localized
nodular pattern in the right upper lobe. (b) Posteroanterior radiograph shows a reticulonodular pattern confned to the
left lower lobe. (c) Posteroanterior radiograph shows a reticular pattern in the right lower lobe accompanied by small,
patchy areas of increased opacity (arrows). (d) Radiograph demonstrates a reticular pattern with mild, hazy
opacifcation in the right lower lobe.
(A) Anteroposterior radiograph from a child with presumptive viral pneumonia. (B) Lateral radiograph of the same child
with presumptive viral pneumonia.
(B) Chest radiography is the primary imaging study used to confirm the diagnosis of pneumonia.
(C) Well-centered, appropriately penetrated, anteroposterior chest radiography is essential (see the
image elow), although other views may e warranted to clarify anatomic relationships and air-
fluid levels.
When considering pneumonia, devote particular attention to the following!
Costophrenic angles
"leural spaces and surfaces
#iaphragmatic margins
Cardiothymic silhouette
"ulmonary vasculature
$ight ma%or fissure
Air ronchograms overlying the cardiac shadow
Lung e&pansion
"atterns of aeration
Be aware that any image reflects conditions only at the instant at which the study was performed.
Because lung diseases, including pneumonia, are dynamic, initially suggestive images may re'uire
reassessment ased on the suse'uent clinical course and findings in later studies.
Limitations of chest radiography
Chest radiography is not always necessary, or even useful, as an aid in determining the etiology of the
infection.
(everal studies, in fact, have demonstrated that chest radiography is )*-+,- accurate in predicting the
etiology of a case of pneumonia. .or e&ample, in a study of /01 children with pneumonia, * radiologists
who independently evaluated all chest radiographs were unale to distinguish whether the agent involved
was acterial, viral, or unidentified.
2/3
4iven the fre'uency of nonspecific findings otained with imaging, clinical presentation and other
laoratory findings must e considered in the diagnosis of pneumonia and in the determination of the
etiologic agent.
Indications for chest radiography
Chest radiography is indicated in an infant or toddler who presents with fever and any of the following!
5achypnea
6asal flaring
$etractions
4runting
$ales
#ecreased reath sounds
$espiratory distress
7n older children and adolescents, the diagnosis of pneumonia is often ased on clinical presentation.
Chest radiography also helps to confirm the diagnosis of a child with positive 8antou& test results. 7f the
chest radiography findings are positive or if the child has other symptoms consistent with the diagnosis of
tuerculosis, an attempt should e made to isolate the tuerculous acilli from early-morning gastric
aspirates, cererospinal fluid, sputum, urine, pleural fluid, or iopsy specimens.
Chest radiography is indicated in complicated cases in which treatment fails to elicit a response, in
patients with respiratory distress, or in those who re'uire hospitali9ation. :tain frontal and lateral
radiographs, particularly in cases in which the clinical e&amination findings are e'uivocal.
7n complicated cases of pneumonia, perform chest radiography 0 wee;s after treatment to verify
resolution of the pneumonia and to screen for any underlying predisposing conditions, such as
se'uestration.
Radiographic patterns of pneumonia
6umerous radiographic patterns are consistent with pneumonia and a multitude of other pathologic
processes.
2*3
A synthesis of all availale information and careful consideration of the differential diagnosis
is essential to estalishing the diagnosis, although empiric antimicroial treatment usually cannot e
deferred ecause of an inaility to prospectively e&clude the diagnosis.
4enerali9ed hyperinflation with patchy infiltrates suggests partial airway ostruction from particulate or
inflammatory deris, although the contriution of positive airway pressure from respiratory support must
e considered. "neumatoceles (especially with air-fluid interfaces) and prominent pleural fluid collections
also support the presence of infectious processes.
Chest radiographs of infants infected with organisms in utero or via the maternal genital tract may
demonstrate a ground-glass appearance and air ronchograms. #iffuse, relatively homogeneous
infiltrates that resemle the ground-glass pattern of respiratory distress syndrome are suggestive of a
hematogenous process, although aspiration of infected fluid with suse'uent seeding of the loodstream
cannot e e&cluded.
"atchy, irregular densities that oscure normal margins are suggestive of antepartum or intrapartum
aspiration, especially if such opacities are distant from the hilus. "atchy, irregular densities in dependent
areas that are more prominent on the right side are more consistent with postnatal aspiration.
<&cept for patients with sic;le cell disease, a significant pleural effusion usually indicates a acterial
etiology. Although these patterns are typical, the etiology cannot e relialy identified ased solely on
chest radiography findings. :ther typical findings of acterial pneumonia include a loar consolidation
with air ronchograms occasionally accompanied y a pleural effusion. Loar consolidation and pleural
effusion are seen in the images elow.
$ight lower loe consolidation in a patient with acterial pneumonia.
$adiograph from a patient with acterial pneumonia (same patient as in the preceding image) a few days later. 5his
radiograph reveals progression of pneumonia into the right middle loe and the development of a large parapneumonic
pleural effusion.
(ingle or multiple prominent air ronchograms * or more generations eyond the mainstem ronchi
reflect dense pulmonary parenchyma (possily an infiltrate) highlighting the air-filled conducting airways.
A well-defined, dense loar infiltrate with ulging margins is unusual. Lateral or oli'ue pro%ections may
help to etter define structures whose location and significance are unclear.
Although unilateral and=or loar infiltrates are often seen in acterial pneumonia (see the image elow),
several studies have found that the pattern of radiologic features cannot accurately distinguish a acterial
etiology from a viral etiology.