Late‐onset, unusual neurological symptoms in children with mycoplasma infection

Abstract

Mycoplasma infections involve pulmonary and various extrapulmonary organs, but the importance to each organ of direct invasion and cytotoxicity has not yet been determined. Immune responses to Mycoplasma pneumoniae infection result in the production of a large number of autoantibodies against lung, liver, erythrocytes, heart, and brain, 1 possibly due to crossreactivity between M. pneumoniae and human tissue antigens. 2 Production of these autoantibodies may well be responsible for the manifestations of mycoplasma infection. Central nervous system (CNS) complications such as meningoencephalitis, transverse myelitis, Guillain-Barré syndrome (GBS), and psychosis can occur in patients with M. pneumoniae infection. 3 The antibody against galactocerebroside (Gal-C), a major glycolipid antigen in the myelin, has been identified in sera from patients with GBS 2 and leukoencephalitis, 4 and may participate in the demyelination process in these cases. Although immune reactions may thus have a crucial role in the pathogenesis of brain involvement, the efficacy of steroid treatment in mycoplasma encephalitis remains controversial.We describe here two patients with presumed post-infectious insults in the CNS, for which immune-mediated pathology was assumed. We emphasize the relapsing and self-limiting nature of the clinical course, and the significance of hypoperfusion on neuroimaging for the diagnosis of this condition. Case reports Patient 1A 9-year-old boy suffered from febrile illness with cough for several days. The fever resolved after administration of clarithromycin, but re-emerged on the 11th day of illness. The diagnosis of mycoplasma pneumonia was made on day 15, and treatment with azithromycin was commenced. He became afebrile by day 16, but appetite loss and apathy appeared at this time. He also became emotionally labile, and he bit his mother on the hand. Mild disturbance of recent memory was noted. He was admitted to hospital on day 21 of illness, when examination of cerebrospinal fluid (cell count, 2/mm 3 ; protein, 14 mg/dL) and brain computed tomography were normal. Electroencephalography (EEG) showed increased slow waves at bilateral frontal areas (Fig. 1a). With suspicion of mycoplasma encephalitis, he was treated with 0.15 mg/kg dexamethasone for 5 days. Conversation became fluent, and he was discharged with almost complete recovery. Inappropriate crying and apathy, however, developed 1 week after cessation of steroid therapy.The patient experienced visual hallucinations, and at times could not recognize his father. He was referred to Tottori University Hospital at this time (Fig. 2). Upon examination his gait was not disturbed but he preferred to lie down. He responded to questions by nodding or in single words. He could state his name, but could not remember his age. Mild disorientation was noted. Otherwise, neurological examination did not indicate any abnormalities. After admission he remained lying on the bed, and ate food directly with his hands. His white blood cell count was 11 400/mL, and his se...

Use of corticosteroids in Mycoplasma pneumoniae encephalitis: A case report and review of literature

“…In the CEP study, eighty percent of 84 patients were positive for M. pneumoniae by serology alone [11], and CSF -PCR for M. pneumoniae was rarely positive (2%) [11], The presence of IgM antibodies specific to M. pneumoniae are a reliable determinant of acute infection since they typically appear within 1 wk of the initial infection [39]. It is widely held that immunological sequelae of M. pneumoniae infection account for some of the neurologi-cal complications [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40], which supports the use of corticosteroids in treatment. There are both identified case series and case reports of use of corticosteroids in patients of Mycoplasma pneumonia CNS involvement.…”

“…Since autoimmunity has been suggested as a mechanism of CNS involvement; this has led clinicians to consider the use of corticosteroids for these patients. Its use has been described in case reports and case series and has shown good results [20,[24][25][26][27][28][29][30][31][32][33][34][35]. We report here a severe case of mycoplasma-associated encephalitis that had full recovery with the use of high dose corticosteroids.…”

Mycoplasma pneumonia in Cerebrospinal Fluids of Febrile Children With Neurologic Manifestations: A Cross Sectional Study: Tehran, Iran

“…Although the positive PCR in CSF are very useful in cases, are insufficient .We prefer to test CSF from both serological and PCR aspect in highly suspicious cases (18). Anti-microbial or immune modulating therapies (Corticosteroids, intravenous immunoglobulin) had possible benefits in treating such complications (19)(20)(21).…”

“…M. pneumonia (DNA-PCR) was the most common agent implicated in unexplained encephalitis in the California Encephalitis Project (14). Many studies recommend various anti-microbial or immune modulating therapies in treating CNS manifestations of M. pneumonia (15)(16)(17)(18)(19)(20)(21).…”

Tics in patients with encephalitis

“…Overall, both the infectious agent and the presentation of the movement disorder show a wide variability, depending on the geographical location. For example, studies conducted in India have shown a higher prevalence of rheumatic fever and tetanus [57] compared to cases of Mycoplasma pneumoniae infection leading to motor abnormalities in both the USA [28] and Japan [58].…”