Combination therapy with immune‐modulators and moxifloxacin on fulminant macrolide‐resistant Mycoplasma pneumoniae infection: A case report

Abstract

This report entails a case of refractory pneumonia with a wild variety of extra‐pulmonary manifestations due to macrolide‐resistant Mycoplasma pneumoniae infection in a 7‐year‐old boy. The diagnosis was based on isolating M. pneumoniae through cultivation from the patient's bronchial aspirations at admission and the following susceptibility testing. Initial treatments consisting of a combination of azithromycin and standard‐dosed methylprednisone (2 mg/kg) were completely nonresponsive and the patient's condition deteriorated rapidly. However, methylprednisone pulse therapy (20 mg/kg for 3 days, tapering within 1 month) and intravenous immunoglobulin (1 g/kg/day, two doses), in addition to moxifloxacin (10 mg/kg for 7 days) were remarkably effective and led to a favorable outcome without any observed side effects during inpatient hospitalization and outpatient follow‐up. Pediatr Pulmonol. 2013; 48:519–522. © 2012 Wiley Periodicals, Inc.

Classification of Extrapulmonary Manifestations Due to Mycoplasma pneumoniae Infection on the Basis of Possible Pathogenesis

“…Since 2000, when the first case of pneumonia due to macrolide-resistant M. pneumoniae was diagnosed in Japan (Okazaki et al, 2001 ), macrolide resistance has grown to be a significant problem in some countries, particularly in eastern Asia. A few cases of extrapulmonary manifestations due to macrolide-resistant M. pneumoniae have been reported (Atkinson et al, 2011 ; Koga et al, 2012 ; Oishi et al, 2012 ; Shen et al, 2013 ; Zhou et al, 2014 ). While the studies from China have reported that a substantial number of complications (most frequently liver and myocardial dysfunctions) occurred in patients infected by resistant strains (Shen et al, 2013 ; Zhou et al, 2014 ), no appreciable increase in the number of extrapulmonary manifestations has been observed in Japan in conjunction with a significant increase in the number of pneumonia patients infected by the resistant strains.…”

Mechanism of resistance acquisition and treatment of macrolide-resistant Mycoplasma pneumoniae pneumonia in children

“…Several studies reported the efficacy of IVIG for severe MPP in children125859). Besides fulminant MPP, there are numerous reports showing that IVIG therapy was effective in treating hemophagocytic syndrome, encephalitis, myocarditis complicated with complete heart block, cold agglutinin-related severe hemolytic anemia, mucositis, Stevens-Johnson syndrome, and acquired hemophilia58606162).…”

Treating paediatric community‐acquired pneumonia in the era of antimicrobial resistance

“…As a matter of fact, severe lung disease due to Mycoplasma pneumoniae was presumed to be determined by overproduction of cytokines and excessive cell‐mediated immune response. Therefore, many investigators suggested that these cases could benefit from combined therapy with antimicrobial agents and immune modulators . Prednisolone (1 mg/kg/day for 3–7 days, tapering within 1 week), methylprednisone (2 mg/kg/day or 20–30 mg/kg for 3 days, tapering within 1 month) and intravenous immunoglobulins (1 g/kg/day, one or two doses) have therefore been successfully used .…”

“…Most studies have shown that fluoroquinolones and tetracyclines have excellent in vitro antimycoplasma activity in children with MRMP pneumonia . Several studies have also reported that children with severe MRMP CAP have been successfully treated with ciprofloxacin, levofloxacin, moxifloxacin, minocycline and doxycycline (Table ).…”

“…However, tetracyclines are not approved for use in children under 8 years old due to the potential for tooth discoloration, and fluoroquinolones are not recommended in children under the age of 18 because of the risk of cartilaginous abnormalities reported in animal models. However, they have been successfully prescribed for severe infection in children, and they do not appear to be associated with arthropathy .…”