casereport mycoplasma pneumonia

8/12/2019 CaseReport Mycoplasma Pneumonia

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CASE REPORT

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General Data

Name: Birth day: 85/04/24

Age: 6 y/oChart number: 15213493 Admission day: 91/05/03

Discharge day: 91/05/20BW: 22 Kg


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Chief Complaint

Fever off and on for 8 days


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Present Illness

A 6 year-old boy suffered from fever offand on for 8 days. He also complained ofcough, rhinorrhea and difficult toexpectorate sputum. He was taken to LMDtwice and our OPD on 91/04/30, but thesymptoms persisted in spite of drugs use.So he was taken to our OPD again on91/05/03. Physical examination revealeddecreased breathing sound on right chest.CXR showed lobar pneumonia.


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Brief history

Birth Hx: GA: 39 Wks, BBW:3050 gm, NSDPrevious admission: Denied

Vaccination: As schedule Allergy Hx: DeniedFood exposure: DeniedDrug exposure: DeniedRecent travel: DeniedFamily Hx: Non-contributory


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Physical Examination:

Vital sign: BT 39.9, PR:120 bpm, RR 32/minGeneral appearance: Acute-ill lookingHEENT: No gross anomaly

Conjunctiva: not injectedThroat: mild injection

Chest: Symmetric expansion

Retraction: nodecreased breathing sound: right lung,fine moist rales(+)

percussion: dullness of right chest


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CBC/DC

5/3 5/7WBC 9100 10110Hgb 11.9 10.6Hct 32.9 29.7

MCV 72.6 75.2PLT 190000 206000

Neut 92.3 89.5

Lym 3.3% 5.5%Mono 2.3% 1.6%Eos 0.3% 0.5%


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Urinalysis5/3 5/4

Appearance Y-CLEAR Y-CLEAR

SP. Gr. 1.010 1.015PH 6.0 6.0

Protein 1+ 1+Glucose - -OB - -Bilirubin - -

Nitrate - -RBC 0-2 8-10WBC 4-6 40-50Bacteria + +


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Biochemistry

Glu BUN Cr AST ALT Na K

5/3 94 6.0 0.5 117 39 125 4.5

5/4 129

5/7 93 3.0 0.5 85 179 137 4.0


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Blood culture

5/3 NO GROWTH

5/7 NO GROWTH


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Urine culture

5/5 NO GROWTH


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Serology

CRP5/4 163 mg/l

5/7 126 mg/l

Mycoplasma Pneumoniae Antibody 5/4 NEGATIVE


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Hospital Course (I)

Initially (5/3), empiric antibiotics withCefuroxime 500mg IV q6h andErythromycin 250mg PO q6h were used,but intermittent high fever up to 39C wasstill noted.Gentamicin was added on 5/4 due topyuria of urinalysis and suspected UTI


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Hospital Course (II)

On 5/5, multiple fine, discrete, rubella-likeskin rashes developed on the face, trunkand extremities with itchy sensation.

Vena infusion and Sinbaby lotion wereused for symptom relief.


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Serology

5/7 IgA 126 (70-400)IgM 105 (40-230)

IgG 778 (700-1600)

5/8 Measles IgM (-)

Rubella IgM (-)


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Hospital Course (III)

On 5/7, followed CXR showed massiveamount of pleural effusion, right lung. Sowe do chest CT, and erythromycin was

changed to 220mg IV q6h

On 5/8, thoracocentasis was done and

showed exudate effusion. So we do chesttube insertion. About 200ml of yellow-reddish fluid was drained.


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Chest CT

Date 91/05/07Impression:

Consolidation of right lower lobeand medial segment of middle lobe,pneumonia is likely. Moderate amountof right pleural effusion and scantyamount of left pleural effusion.


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Abdominal echo

Date 91/05/07Ultrasonic Impression:

Negative finding of abdominalultrasonography


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Pleural Effusion Study (I)

5/8 Pleural fluid Appearance cloudy Color reddish-yellow Bloody (+) Chylous (-) Coagulation (+) Sp. Gr. 1.025


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Pleural Effusion Study (II)

WBC 630 cumm

Polynuclear cells 55.0%Mononuclear cells 45.0% Abnormal cells (-)

Pleural, Acid-Fast Stain: Not Found Pleural, Gram s Stain: Not Found


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Pleural Effusion Study (III)

Pleural Effusion Glucose 71 mg/dl

LDH 3149 IU/L (H) Protein 3.30 g/dl (L)


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Pleural Effusion Study (IV)

Pleural effusion culture

on 5/8 no growthon 5/13 no growth


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Pleural Effusion Study (V)

5/8 Pleural effusion cytology:

No evidence of malignancy5/14 Pleural PCR assay for mycobacteriaresult: Negative


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Hospital Course (IV)

On 5/10, followed CBC/DC showedleukocytosis with left shift (WBC 19570,Neu 92.9%). Persistent high fever wasnoted. So Cefuroxime was changed toCeftriaxone 1g IV q12hHigh fever up to 40C persisted in spite ofCeftriaxone + Gentamicin + Erythromycincombined use


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CBC/DC

5/3 5/7 5/10 5/13 5/15WBC 9100 10110 19570 26450 12270Hgb 11.9 10.6 8.8 8.4 8.9Hct 32.9 29.7 25.2 24.2 25.1

MCV 72.6 75.2 85.7 76.2 74.1PLT 190000 206000 378000 551000 707000

Neut 92.3 89.5 92.9 92.8 87.1Lym 3.3% 5.5% 4.2% 3.5% 6.9%

Mono 2.3% 1.6% 2.2% 1.9% 2.6%Eos 0.3% 0.5% 0.4% 0.8% 1.8%


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Urinalysis5/3 5/4 5/11 5/14

Appearance Y-CLEAR Y-CLEAR Y-CLEAR Y-CLEAR

SP. Gr. 1.010 1.015 1.010 1.020PH 6.0 6.0 5.0 6.5

Protein 1+ 1+ - -Glucose - - - -OB - - - -Bilirubin - - - -

Nitrate - - - -RBC 0-2 8-10 0-2 0-1WBC 4-6 40-50 0-2 8-10Bacteria + + -- --


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Biochemistry

Glu BUN Cr AST ALT Na K Alb5/3 94 6.0 0.5 117 39 125 4.55/4 1295/7 93 3.0 0.5 85 179 137 4.05/9 5.0 0.4 46 99 131 5.25/11 136 3.0

5/14 11.2 0.4 85 1755/16 71 146 3.5


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Blood culture

5/3 NO GROWTH

5/7 NO GROWTH5/11 NO GROWTH


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Urine culture

5/5 NO GROWTH5/10 NO GROWTH

5/12 NO GROWTH


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Serology (I)

CRP5/4 163 mg/l

5/7 126 mg/l5/14 113 mg/l


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Serology (II)

5/13 Direct Coombs test: positiveIndirect Coombs test: positive

5/14 RA< 10.2 IU/ML (


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Serology (III)

5/14 Heterophil Ab: Negative ANA Negative

5/14 Legionella Ab: NegativeChlamydia Ab: Negative


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Ga-67 Inflammation Survey

Date 91/05/15 A patch of abnormal tracer uptake at

the right lower lung field, may beinflammatory focus.Diffusely increase uptake of liver. Thisphenomenon can be found in irondeficiency anemia


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Pleural Effusion Study (II)

5/8 Pleural fluid for Mycoplasmalpneumonia antibody: 80X


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Serology (III)

5/16 Cold hemaglutination: 512 X (


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Hospital Course (V)

Chest tube was removed on 5/13We used prednisolone (2mg/kg/day in 4divided doses) on 5/14. Fever subsided onthe night of 5/14.Steroid was tapered graduallyOn 5/20, patient was discharged understable condition.


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CBC/DC5/3 5/7 5/10 5/13 5/15 5/23

WBC 9100 10110 19570 26450 12270 9780Hgb 11.9 10.6 8.8 8.4 8.9 10.1Hct 32.9 29.7 25.2 24.2 25.1 30.2

MCV 72.6 75.2 85.7 76.2 74.1 78.9PLT 190000 206000 378000 551000 707000 377000

Neut 92.3 89.5 92.9 92.8 87.1 66.1Lym 3.3% 5.5% 4.2% 3.5% 6.9% 22.3

Mono 2.3% 1.6% 2.2% 1.9% 2.6% 10.0Eos 0.3% 0.5% 0.4% 0.8% 1.8% 1.0


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Biochemistry

Glu BUN Cr AST ALT Na K Alb5/3 94 6.0 0.5 117 39 125 4.55/4 129

5/7 93 3.0 0.5 85 179 137 4.05/9 5.0 0.4 46 99 131 5.25/11 136 3.05/14 11.2 0.4 85 1755/16 71 146 3.55/23 21 30


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Serology (I)

CRP5/4 163 mg/l

5/7 126 mg/l5/14 113 mg/l5/30 5.2 mg/l


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Final Diagnosis

Mycoplasmal lobar pneumonia,complicated with prolongedfever, skin rashes, right lungpleural effusion, and hemolytic

anemia


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DISCUSSION


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Mycoplasma Pneumoniae

In 1944, M. pneumoniae was reported byMonroe Eaton, originally called the Eatonagent.

Smallest free-living microorganism,belongs to the class Mollicutes.

Mycoplasmas lack a cell wall, so tend tobe pleomorphic .


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Clinical Manifestations

M. pneumoniae causes approximately 20% of allcases of pneumonia.

Peak incidence at 6-21 years of age.

Incubation period of 2-3 weeks.

Transmission by inhalation of infected dropletaerosols.


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Pneumonia is the most important clinicalmanifestation of M. pneumoniae infection.

* Bronchopneumonia pattern mostly.Lobar pneumonia and large amountpleural fluid are unusual.

Pediat Radiol 1989;19(8):499-503

* Respiratory disease other thanpneumonia: unspecific URI, pharyngitis,

AOM, croup, sinusitis, bronchitis,bronchiolitis, asthma.

Cutaneous manifestations : common


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Cutaneous manifestations : common.* Exanthem and enanthem of Mycoplasma

pneumoniae infection are observed in 5 to24% of cases

AAP, Report of Committee on Infectious Diseases, 1994:333-5

* Most common with an erythematousmaculopapular rash on the trunk and back;discrete (rubelliform) or confluent(morbilliform).

* Most serious presentation: Erythemamultiforme and Stevens-Johnson syndrome .

Clini Pediatrics 1991:30(1),42-9


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Hematologic manifestations:* Hemolytic anemia: usually mild,

however, it may become severe andresult in 50% reduction in hemoglobinconcentration.

Pediat Infec Dis J 1998;17(2):173-7

* Direct Coombs test usually positive.

* Steroid administration may bebeneficial.

South Med J 1990;83(9):1106-8


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Hemolytic anemia is presumablyrelated to the presence of coldagglutinins in serum which at highconcentration, may agglutinateerythrocytes at 37

Rev Pneumol Clin 1990,46(2),83-4


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Gastrointestinal findings are nonspecific withnausea, vomiting, abdominal pain, and/or

diarrhea.

Neurologic disease association was reported2.6-4.8%.* Encephalitis, meningitis, transverse

myelitis, psychosis, Bell palsy andGuillain-Barre` syndrome.

Arthritis in association with M.pneumoniaeinfection have not been established.


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Hepatitis was once thought to beunusual, but recent studies suggestthat liver dysfunction may be presentin up to 30% of M. pneumoniaeinfection.

Pediatr Pulmonol 1990;8:182-7


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Liver dysfunction was observedmore frequently in patients withpleuropneumonia than in simple

pneumonia cases.



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Radiographic Manifestation (I)

Interstitial infiltration was more commonlyseen in pediatric than adult patients (46% vs20%)

Unilateral lesions 80%Single lobe lesions 77%Lower lobe predominant 69%

Pleural effusion 7%

1993;9(4):204-11


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Radiographic Manifestation (II)

Unilateral infiltration 84%Lower lobe predominance 60%

Confluent consolidation 56%Patchy consolidation 33%Pleural effusion 24%

1991;14(3):156-62


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Diagnosis (I)

WBC, CRP, ESR are non-specific, may benormal or elevated.Growth of the organism takes weeks,

generally only in expertise laboratories.PCR is sensitive and specific.Serologic testing : Cold agglutinins, titer of

>1:64 is suggestive of infection; Anti-mycoplasmal Ab detection, fourfold orgreater rise are considered diagnostic.


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Diagnosis (II)

Imaging : Interstitial infiltrate or

bronchopneumonia pattern. Lobarconsolidation and pleural effusion areuncommon but may occur.

T


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Treatment Erythromycin is the drug of choice.

(40-50mg/kg/24hr q6h for 10-14 days). Newer macrolides:

Azithromycin (10mg/kg on day 1, and5mg/kg/24hr on days 2-5) or

Clarithromycin (15mg/kg/24hr given in two

divided doses for 10 days).


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Empiric Therapy for Lobar Pneumonia

Clinically moderate to severely toxic,treat empirically for S. pneumonia, S.pyogens ( and H. influenzae type b inunimmunized children)

In toxic children, tests for Mycoplasmashould be considered because focalpneumonia is a rare presentation


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Cefuroxime intravenously, ceftriaxoneor cefotaxime intravenouslyFor anti-staphylococcal coverage, addto the above, either: nafcillin, oxacillin,or clindamycinFor Mycoplasma: intravenouserythromycin or azithromycin; or oralerythromycin, azithromycin, orclarithromycin.


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Pneumonia, with pleural fluid or empyema

Treat empirically for S. pneumonia, S.pyogenes, and S. aureus ( and H.influenzae type b in unimmunized children)

Consider aspiration pneumonia withanaerobic oral flora as pathogens; needle

or catheter aspiration of pleural fluid, withdrainage, is often required for clinical cure.


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Ceftriaxone or cefotaxime

For antistaphylococcal covarage, add to theabove either: nafcillin, oxacillin, orclindamycin (also covers anaerobes found in

aspiration pneumonia as well as mostpneumoncocci)

Single agent therapy with meropenem, orticarcillin/clavulanate (Timentin) both ofwhich cover both aerobic and anaerobicpathogens


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CONCLUSION


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Presence of pleuropneumoniaappears to be associated withmore severe and prolongedcourse of illness



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Even in patients with clinicallymild pneumonia, Mycoplasmapneumoniae may be the causeof severe anemia

Ann of Hematol 2001;80(3):180-2


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Association of exanthem andpneumonia or of hemolyticanemia and pneumonia are

considered to be stronglysuggestive for the diagnosis of M.pneumonia infection

Clin Infec Dis 1993;17(Suppl 1):S47-51


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