Cases of pneumonia are often diagnosed presumptively based on the clinical presentation and perhaps a radiograph. Chest x-ray findings in viral pneumonias include patchy or streaky, often bilateral, interstitial patterns and hyperinflation of the lungs. Bacterial pneumonias show classic lobar consolidation and alveolar infiltrates, although x-ray findings typically lag behind the clinical course by 1 to 2 days and can be completely normal on day 1. Parapneumonic pleural effusions can also occur.

Sputum Gram stain and culture may be performed but have a low yield. Some bacterial agents such as Legionella may be identified by antigen detection from blood samples. Mycoplasma pneumoniae may be diagnosed with a positive cold agglutinin test of peripheral blood. Sputum smears and cultures for acid-fast bacilli (AFB) are appropriate when there has been possible contact with tuberculosis patients, in TB-endemic areas, or when clinical findings suggest TB. Invasive procedures (e.g., BAL, lung aspiration, bronchos-copy) are reserved for special circumstances, such as diagnosing pneumonia in the immunocompromised host or in ventilator-associated pneumonias.

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