The chest radiograph is considered the pragmatic reference standard for making the diagnosis. 25 The finding of consolidation on radiograph is thought to be a reliable sign of pneumonia.32

Differentiating the various microbiologic causes of pneumonia is often more difficult. Typical patterns of clinical presentation and epidemiologic data on incidence have been described above but often overlap. Radiographically, viral pneumonias tend to appear as diffuse interstitial infiltrates, frequently with hyperinflation, peribronchial thickening, and areas of atelectasis. Bacterial pneumonias tend to have lobar or segmental consolidation. Pneumatocele formation and a combination of pneumothorax and empyema are highly suggestive of S. aureus infection. However, bacterial pneumonias with perihilar interstitial and nodular patterns on radiographs have been reported.3 34 Chlamydia trachomatis infections usually lead to hyperexpansion and diffuse alveolar or perihilar interstitial infiltrates. Radiographic patterns in M. pneumoniae infections are variable. Lower-lobe streaky or patchy infiltrates are the most common, but many other patterns are possible, including lobar infiltrates in 10 to 25 percent of cases. Viral pneumonias can also cause lobar or segmental consolidations. 34 Several studies have looked at the accuracy of the chest radiograph in differentiating viral from bacterial disease. A recent review of these studies found sensitivities ranging from 42 to 80 percent and specificities of 42 to100 percent.25

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