Mycoplasma Pneumonia Meningitis

pediatrics.uchicago.edu

Mycoplasma Pneumonia Meningitis

Morning Report

December 12, 2005

Luba Romantseva, Romantseva,

PL-2

PL


History

12 yo AA boy, who was treated at OSH for pneumonia, acutely

develops mental status changes and unresponsiveness

Re MS changes: admitted 2 days ago for pneumonia, today became

progressively noninteracitve, noninteracitve,

grunting respirations, no response to

commands

Re pneumonia: fever 102.6 F and productive cough for ~10 days

pta, pta,

pt was seen in clinic 7 days pta, pta,

and given Amoxicillin, after 3

days developed diarrhea, was admitted for inpatient treatment, CXR CXR

revealed RML opacity, pt was started on Cefazolin. Cefazolin.

Throughout

hospital stay, pt continued to have fevers, cough and worsening

Right-sided Right sided chest pain.

Other treatments: pt noted to have Hg=7, and was transfused 300

cc pRBC 2 days prior to MS changes


History

PMH: Sickle cell dz, dz,

typical Hg 7.5-8, 7.5 8, 1 VOC in 2/05, no

hx CVA, no gallbladder dz, dz,

no spleen problems, no

previous transfusions

ROS: no recent trauma, no episodes of weakness,

numbness, confusion or abnormal gait prior to the onset

of sx, sx,

no hx of ingestion


Physical Exam

VS: T 36.5 HR 85 RR 26 BP 125/65 100% on vent

GEN: sedated, intubated, intubated,

minimally responsive

HEENT: pinpoint pupils, ETT in place

CV: RRR, nl S1, S2, no murmurs

Pulm: Pulm:

coarse BS, anterior RML crackles

Abd: Abd:

S, NT, ND

Neuro: Neuro:

nonresponsive,

nonresponsive,

dec tone, dec DTR’s, DTR , +Babinski + Babinski

bilat, bilat,

+ corneal reflex, + dolls eye reflex, no gag, no

cough, extensor posturing present with deep stimulation


Increased ICP initial management

Stabilize pt

ABC’s, ABC s, IV access

Relieve increased ICP (CPP=MAP-ICP)

(CPP=MAP ICP)

EVD to monitor ICP

Intravascular

Elevate HOB 30 degrees, keep head midline

Hyperventilation to pCO2 30-35 30 35 mm Hg

Sedate, normothermia/slight normothermia/slight

hypothermia

Consider Pentobarbital coma

Extravascular

Consider Decadron IV, Osmotic diuretics


DDx of Acute Encephalopathy

Neurologic

Stroke, Seizure/postictal

Seizure/ postictal state

Infectious

Encephalitis, Meningitis

Trauma

Metabolic

DKA, electrolyte abnormalities

Toxic ingestion/overdose

Cardiac

arrhythmia, arrest

Endocrine

adrenal, parathyroid, thyroid

Renal/Liver


Initial Work-up Work up

Head CT: brain edema but no bleed, no mass effect, no midline shift shift

Brain and spine MRI: edema, abnl diffuse T2 enhancement in

thalami, brainstem to spinal cord down to conus medullaris

CBC3, BMP, coags, coags,

LFT’s LFT

CXR: R upper/middle lobe pneumonia

LP: opening pressure 36, prot 57, glu 79, 2RBC, 13 WBC

(9N/63L/25M)

EEG: nl


Infectious causes of Encephalitis


Common pathogens of Encephalitis


Our patient’s patient s ID work-up work up

Blood, urine, CSF cx neg

PPD neg, neg,

CSF AFB cx neg

Strep. Pneumo urine Ag neg

HSV CSF PCR neg

Enterovirus CSF PCR, throat and

rectal swabs: neg

Cryptococcal Latex Ag neg

Bartonella serologies neg

Arbovirus panel (EEE, WEE, CA,

St. Louis) serologies neg

West Nile CSF and serologies neg

Latex agglutination test for H. flu,

N. meningiditis,

meningiditis,

Strep.pneumo,

Strep.pneumo,

E.coli: neg

Initial LP: opening pressure 3614 36 14, ,

prot 57, glu 79, 2RBC, 13 WBC

(9N/63L/25M)

Repeat LP: opening pressure 8, prot

57, glu 84, 440 RBC, 8 WBC

(2N/85L/13M)

Mycoplasma IgM 128 (16), IgG

>512 (32)

Mycoplasma Ab by Complement

Fixation in CSF: 1:4, positive

Repeat Mycoplasma IgM, IgM,

IgG: IgG:

elevated

Repeat Mycoplasma Ab by CF in

CSF:


Mycoplasma Encephalitis

Prevalence:

Neurologic involvement occurs in 0.1% M. pneumoniae infections and

7-10% 10% of those hospitalized for M. pneumoniae

Encephalitis is the most common extrapulmonary manifestation of M.

pneumoniae infection

M. pneumoniae encephalitis accounts for 5-10% 5 10% of all childhood acute

encephalitis cases

Encephalitis is more common in children vs adults, mean age is 6-8 6 8 yo

Clinical picture:

Encephalitis (altered MS, focal neurologic abnl, abnl,

sz) sz)

is most common, but

meningitis, transverse myelitis, myelitis,

Guillain-Barre

Guillain Barre syndrome, ADEM, and

stroke have also been observed

Recent URI sx (cough and sore throat) are common

Prodrome of fever, H/A, emesis is common in those w/o URI sx


Mycoplasma Encephalitis

Diagnosis

Cx: Cx:

gold standard but very difficult to grow the organism

CSF and respiratory Mycoplasma PCR:

very sensitive and specific, good agreement with cx

Serology: Mycoplasma IgM(w/in IgM(w/in

1 wk of illness) and IgG(w/in IgG(w/in

2-3 2 3 wks)

Detection by ELISA

By complement fixation, seroconversion defined by 4-fold 4 fold rise in

titre between acute and convalescent sera

Cross-reacts Cross reacts with other antigenslow antigens low specificity

Other supportive tests:

Abnormal LP(60%): pleocytosis, pleocytosis,

lymphocyte predominant, prot >40

Abnormal EEG(80%): generalized/focal slowing, seizures

Imaging: MRI is more sensitive than CT for subtle lesions, see

focal/generalized edema


Mycoplasma Encephalitis: Proposed

Pathogenesis

Direct invasion of brain parenchyma: organism colonizes

oropharynxblood

oropharynx blood stream infectionCNS infection CNS invasion across BBB

pts w/acute encephalitis, prodrome 5d: neg CSF

PCR but positive serology

Mycoplasma

Immune-mediated mediated vascular injury/hypercoagulable

injury/ hypercoagulable state

pts with Mycoplasma-associated Mycoplasma associated stroke, neg CSF PCR, positive serology

Immune


Mycoplasma Encephalitis

Treatment:

Macrolides(Azithromycin),

Macrolides(Azithromycin),

Tetracyclines(Doxycycline),

Tetracyclines(Doxycycline),

Fluoroquinolones(Cipro), Fluoroquinolones(Cipro),

or Chloramphenicol(bone marrow aplasia risk)

Drug must have good BBB penetration

Consider Steroids, IVIG, Plasmapharesis if suspect immunologic injury

rather than direct invasion

Disease severity and Prognosis:

In a recent study, 30% of patients required an ICU stay

Overall, prognosis is variable

Mortality of 5-10% 5 10% reported

Long-term Long term neurologic sequelae in 20-60% 20 60%

Epilepsy, hydrocephalus, global neurologic deficits with

brainstem dysfunction


Back to our patient… patient

Hospital course

12 day ICU stay, extubated on ICU day 10

26 day HemeOnc inpatient stay

Abx: Abx:

Azithro, Azithro,

switched to Doxycycline x 14 days, Ceftriaxone x 14 days

Timeline of neurologic exam improvement:

ICU stay: spont eye opening, min spontaneous mvt and response to pain

HemeOnc: HemeOnc:

inc alertness, gradually regained ability to follow commands(HD#23),

commands(HD#23),

speak(HD#30), read(HD#32); improved motor function

Repeat MRI: dec in previously seen abnl signal in thalami, brainstem and spinal

cord; mild diffuse cerebral volume loss

Admitted to La Rabida for rehab; at that time main deficits included dec strength L

side, mostly LE, incontinence, poor trunk control, inability to walk

Looking back, likely mechanism of CNS injury:

Autoimmune cross-reaction, cross reaction, given 12 days of URI sx


References

Lewis, P. Encephalitis. Pediatrics in Review 2005; 26: 347-356 347 356

Lin, W. Mycoplasma pneumoniae encephalitis in childhood. J Microbiol Immunol

Infect 2002; 35:173-178

35:173 178

Tsiodras, Tsiodras,

S. Central Nervous system manifestations of Mycoplasma pneumoniae

infections. Journal of Infection 2005; 51:343-354

51:343 354

Bitnun, Bitnun,

A. Mycoplasma pneumoniae encephalitis. Seminars in Pediatric Infectious

Diseases 2003;14:96-107

2003;14:96 107

ACKNOWLEDGEMENTS

Many thanks to Dr. Jannine Joyce for graciously sharing this patient with me ☺

Thanks to Dr. Marcinak and Dr. Ambereen Alam from Peds ID

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