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Key Features

Essentials of Diagnosis

  • Upper respiratory infection prodrome (fever, coryza, cough, hoarseness)

  • Wheezing or rales

  • Myalgia, malaise, headache (older children)

General Considerations

  • Viral infection is a common cause of community-acquired pneumonia in children; responsible viruses in most cases follow:

    • Respiratory syncytial virus (RSV)

    • Parainfluenza (1, 2, and 3) viruses

    • Influenza (A and B) viruses

    • Human metapneumovirus

  • Viral pneumonia is most common in children younger than 2 years

  • Viral infections may predispose to bacterial pneumonia

Clinical Findings

Symptoms and Signs

  • Wheezing or stridor may be prominent in viral disease

  • However, other findings that are similar to those in bacterial pneumonia include

    • Cough

    • Signs of respiratory distress (tachypnea, retractions, grunting, and nasal flaring)

    • Rales and decreased breath sounds

Differential Diagnosis

  • Same as for bacterial pneumonia

  • Patients with prominent wheezing may have

    • Asthma

    • Airway obstruction caused by foreign body aspiration

    • Acute bacterial or viral tracheitis


Laboratory Findings

  • Peripheral white blood cell count

    • Can be normal or slightly elevated

    • Not useful in distinguishing viral from bacterial disease

  • Rapid viral diagnostic methods, such as fluorescent antibody tests, enzyme-linked immunosorbent assay, and/or polymerase chain reaction (PCR), should be performed on nasopharyngeal secretions to identify a viral etiology in high-risk patients as well as for epidemiology or infection control


  • Chest radiography

    • Frequently show perihilar streaking, increased interstitial markings, peribronchial cuffing, or patchy bronchopneumonia

    • Lobar consolidation or atelectasis may occur

    • Hyperinflation of the lungs may occur when involvement of the small airways is prominent


  • General supportive care for viral pneumonia does not differ from that for bacterial pneumonia

  • Because bacterial disease often cannot be definitively excluded, antibiotics may be indicated.

  • Patients at risk for life-threatening RSV infections should be hospitalized and ribavirin should be considered

  • Children with suspected viral pneumonia should be placed in respiratory isolation



  • Viral pneumonia or laryngotracheobronchitis may predispose the patient to subsequent bacterial tracheitis or pneumonia as immediate sequelae

  • Bronchiolitis obliterans or severe chronic respiratory failure may follow adenovirus pneumonia

  • Bronchiectasis, chronic hypersensitivity pneumonia, and unilateral hyperlucent lung (Sawyer-James syndrome) may follow measles, adenovirus, and influenza pneumonias


  • Most children recover uneventfully

  • Patients with adenovirus infection or those concomitantly infected with RSV and second pathogens (such as influenza, adenovirus, cytomegalovirus, or Pneumocystis jirovecii) have a worse prognosis


Esposito  S: Antibiotic therapy for pediatric community-acquired pneumonia: do we know when, what and for how long to treat? Pediatr Infect Dis 2012;31(6):e78–e85
[PubMed: 22466326] .

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