Intravenous Immunoglobulin as a Therapeutic Option for Mycoplasma pneumoniae Encephalitis

Abstract

Objective: To analyze the outcomes of a cohort of children diagnosed with Mycoplasma pneumoniae encephalitis whose treatment regimens included intravenous immunoglobulin (IVIG). Methods: A retrospective study was performed at a single center between 2011 and 2016 of children diagnosed with Mycoplasma pneumoniae encephalitis whose acute treatment regimen included IVIG. Details of therapeutic interventions and the clinical course were retrieved from medical records via an institutionally approved protocol. The modified Rankin score was used to quantify outcomes. Results: Four children met inclusion criteria, 3 of whom had prodromal symptoms of infection lasting 5 to 7 days before onset of their neurologic symptoms. One patient presented with neurologic symptoms with no clinical prodrome. The initial treatment regimen included systemic corticosteroids, antibiotics, or both. IVIG was administered for a total dose of 2 g/kg divided over 2 to 4 days to all 4 children. All children showed clinical improvement after IVIG. The 3 children with prodromal symptoms showed immediate and dramatic clinical improvement after IVIG therapy. Discussion: The immediate response to immunomodulatory therapy in the patients with prodrome suggests that the neurologic syndrome may be caused at least in part by an autoimmune process. The child who did not respond to IVIG had no prodrome, and also had normal electroencephalographic (EEG) and brain magnetic resonance imaging (MRI) findings. These cases suggest that early administration of IVIG should be considered in patients suspected of having Mycoplasma encephalitis, particularly in those who have had prodromal symptoms.

Determining the Clinical Characteristics, Treatment Strategy and Prognostic Factors of Mycoplasma Pneumoniae Encephalitis in Children: A Multicenter Study from China

“…In our cohort, the higher presence of prodromal respiratory symptoms and relatively lower detection of M. pneumoniae in CSF suggested immunologically mediated infection rather than direct invasion was the most common cause, so,the immune modulatory therapy should be considered.Our study also found that azithromycin combined with IVIG or corticosteroid therapy was correlated with shorter lengths of stay and symptom control than the azithromycin group alone, especially in the IVIG-combined group. However, in our study, the length of prodromal symptoms did not affect the e cacy, which is in contrast to Daba's study [9],and should be explained by multiple mechanisms involved in the pathogenesis of MPE.Interestingly, the group that received IVIG and corticosteroids with azithromycin did not show this advantage, which may be related to more critically ill cases in this group.…”

“…A single-center cohort study by Mebratu Daba et. al showed that early administration of IVIG should be considered in patients with suspected MPE, particularly in those with prodromal symptoms of infection for approximately a week or longer and no response to other therapies [9]. In our cohort, the higher presence of prodromal respiratory symptoms and relatively lower detection of M. pneumoniae in CSF suggested immunologically mediated infection rather than direct invasion was the most common cause, so,the immune modulatory therapy should be considered.Our study also found that azithromycin combined with IVIG or corticosteroid therapy was correlated with shorter lengths of stay and symptom control than the azithromycin group alone, especially in the IVIG-combined group.…”

“…However,the role of immune-modulating therapies, such as corticosteroids, IVIG, or plasmapharesis, in the management of MPE remains unde ned because of the lack of conclusive evidence from controlled studies in favor of such therapies, with most studies being case reports. The common assumption is that immune modulating therapies should be considered in those with immune-mediated syndromes such as acute disseminated encephalomyelitis or in those with prodromal symptoms [5,9]. Some research suggested that corticosteroids should be used in patients diagnosed with M. pneumoniae who also show severe extrapulmonary complications, and methylprednisolone should take precedence as rst recommendation [27][28][29].…”

“…According to the duration of prodromal symptoms (de ned as any illness that precedes neurologic symptoms), MPE is divided into early-onset form (prodromal symptoms for 7 or fewer days) and late-onset form (more prolonged prodromal symptoms). The early-onset form is mainly related to the direct invasion of the central nervous system (CNS) by M. pneumoniae, while the late-onset form is usually characterized by an autoimmune of CNS disease principally [1,9].The multiplicity of possible mechanisms suggests that a range of therapeutic approaches should be considered. It is widely accepted that antibiotics play a key role in the management of all children with suspected MPE [1].…”

Refractory Mycoplasma pneumoniae Pneumonia in Children: Early Recognition and Management

“…Some authors advocated intravenous methylprednisolone at 4 mg/kg/day, followed by an increase to 6 mg/kg/day if fever persists [ 139 ]. Furthermore, IVIG might be indicative for those with neurologic impediments [ 142 , 143 ] or with uncontrollable rash and mucositis [ 144 , 145 ]. Still, to arrive at the optimal regimen and to draw sufficiently credible conclusions, more clinical studies are urgently needed [ 94 ].…”