The Turkish Journal of Pediatrics
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Mycoplasma pneumoniae-associated transverse myelitis with unexpected rapid response to macrolide therapy: a case report
Hasan Tezer1, Ateş Kara1, Göknur Haliloğlu1, İlker Devrim1, Kader Karlı-Oğuz2, Deniz Sül1
1Departments of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
2Departments of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
|Tezer H, Kara A, Haliloğlu G, Devrim İ, Karlı-Oğuz K, Sül D.
Mycoplasma pneumoniae-associated transverse myelitis with unexpected rapid response
to macrolide therapy: a case report. Turk J Pediatr 2008; 50: 585-588.|
A seven-year-old boy admitted with the complaints of fever, weakness in legs,
sensory loss in lower limb, and difficulty in voiding lasting for two weeks.
His initial symptoms also included cough and fever. His spinal magnetic
resonance imaging scan demonstrated acute transverse myelitis, and Mycoplasma
pneumoniae-specific IgM and IgG antibodies were found to be positive in
cerebrospinal fluid (CSF) and serum samples. He was treated with a single
high-dose intravenous immunoglobulin (2 g/kg/dose) and clarithromycin.
Mycoplasma pneumoniae is a frequent cause of upper and lower respiratory
tract infections in children. Central nervous system (CNS) manifestations are
among the most frequent extrapulmonary complications during the course
of the disease. They occur most frequently in children, usually within three
weeks after the onset of respiratory illness, with an incidence of approximately
1 in 1,000 patients.
In this report, we present a seven-year-old boy with transverse myelitis during
the course of Mycoplasma pneumoniae infection with serological confirmation
both in serum and CSF samples.
Mycoplasma pneumoniae, transverse myelitis, clarithromycin, intravenous immunoglobulin
|Mycoplasma pneumoniae is a common cause
of acute respiratory tract infections and
atypical pneumonia, particularly in children
and young adults[1,2]. Although the main
presentation of M. pneumoniae infection is
respiratory system involvement, there has
been increasing evidence of extrapulmonary
manifestations due to M. pneumoniae, with the
wide spectrum including neurologic, cardiac,
dermatologic, musculoskeletal, hematologic,
and gastrointestinal manifestations.|
The most serious nervous system complications
of M. pneumoniae infections are acute
transverse myelitis and acute disseminated
encephalomyelitis[4,5]. Pathogenesis of central
nervous system (CNS) disease caused by
M. pneumoniae is incompletely understood but
autoimmune phenomena seem to have a major
role in the development of myelitis.
Acute transverse myelitis is characterized by
motor, sensory and autonomic dysfunction
due to demyelinization of the spinal cord and neuronal damage following focal inflammation.
Parainfectious causes account for 30-60% of the
cases. Differential diagnosis includes vascular,
infectious, neoplastic, autoimmune, collagen
vascular and demyelinating conditions. An
idiopathic group has also been defined since
they are not related to any systemic diseases
and etiology could not be defined.
We report our experience in a seven-year-old
boy with acute transverse myelitis due to
Mycoplasma pneumoniae infection, with rapid
improvement after macrolide therapy.
|Case Presentation |
|A seven-year-old boy with an unremarkable
medical history was referred to our hospital
with the complaints of fever, weakness in
legs, sensory loss in lower limb, and difficulty
in voiding lasting for two weeks. His initial
symptoms included cough and fever. On
physical examination, his vital signs were
unremarkable. His neurological examination revealed a fully oriented boy. Deep tendon
reflexes at lower extremities were absent
bilaterally and there was marked proximal
and distal muscle weakness. Babinski sign
was positive bilaterally. Sensory examination
showed diminished temperature and pain
sensation below the level of T10. He had stool and urine incontinence with neurogenic
bladder. Other systemic physical examination
findings were unremarkable. Laboratory
investigation revealed that his white blood
cell count, hemoglobin level and platelet count
12.7 g/dl, and 189000/mm3, respectively. Initial cerebrospinal fluid (CSF)
examination (which was done in another center
two weeks before referral to our clinic) revealed
73 leukocytes/µl and CSF biochemical values
were as follows: protein 220 mg/dl and glucose
62 mg/dl. CSF examination performed in our
hospital at the time of admittance revealed
clear CSF with protein value of 32 mg/dl and
glucose 54 mg/dl. Electromyography revealed
involvement of anterior horn motor neurons in
L3-L5, S1 lumbosacral roots. His spinal magnetic
resonance (MR) imaging scan demonstrated
diffuse involvement of the spinal cord by
mild swelling, increased T2 signal intensity
) and patchy contrast enhancement
(Fig. 1c) at the level of C3-T11 suggestive of acute myelopathy. There was also contrast
enhancement of the caudal roots (Fig. 1c). He
was treated with a single high-dose intravenous
immunoglobulin (IVIG) (2 g/kg/dose) with
the diagnosis of acute transverse myelitis.
Mycoplasma pneumoniae-specific IgM and IgG
antibodies were found to be positive in CSF
and serum samples. Clarithromycin was added
to his supportive therapy on the second day of
hospitalization. His muscle strength increased at the tenth day of clarithromycin therapy, and
urine and stool incontinence started to resolve
after 12 days of treatment. Clarithromycin
therapy was stopped at the 14th day. He was
discharged with mild lower limb weakness on
the 14th day and his follow-up examination was
normal after one month.
| ||1a, b|
| ||Fig 1: Sagittal (a) and axial (b) T2-weighted (W) turbo spin-echo (SE) (TR/TE; 3800/100 ms) images show
diffusely increased signal intensity and subtle enlargement of the spinal cord in a long segment. Patchy mild
enhancement of the spinal cord and diffuse enhancement of the caudal nerve roots are seen on
sagittal postcontrast T1-W SE (TR/TE; 500/15 ms) (c).|
|Mycoplasma pneumoniae is a common respiratory
pathogen. Extrapulmonary complications of
M. pneumoniae infection include neurologic
complications involving the central and
peripheral nervous systems and occur in 0.01-
4.8% of M. pneumoniae-infected patients. Among
the neurologic complications, encephalitis is the
most frequently encountered complication of M.
pneumoniae, followed by acute transverse myelitis
and encephalomyelitis. It is characterized by
demyelination and focal inflammation of
the spinal cord causing neuronal damage.
The pathophysiology behind the CNS
symptomatology in M. pneumoniae-associated
diseases remains hypothetical. It is suggested
that the complications may result either from
direct invasion of M. pneumoniae into the
neural tissue, a neurotoxin produced by the
organism, or an immune-mediated damage.
The immune-mediated injury could be caused
by cross-reacting antibodies to antigens shared
by mycoplasma and the brain, organisminduced
immunosuppression, immune complex
vasculopathy, or vascular microthrombi.|
In the majority of the patients who have
M. pneumoniae-associated transverse myelitis,
respiratory system infection develops around 10
days prior to neurological findings. However,
it has been shown in various studies that this
period may vary from 1 day to 30 days. Clinical
findings may range from non-specific upper
respiratory tract infections to pneumonia.
Likewise, our patient had respiratory system
findings such as cough 12 days before
presentation to our hospital.
Serological methods are used frequently for
the diagnosis of M. pneumoniae. Yet, there
are patients with negative serology even if
positivity is demonstrated with polymerase
chain reaction. As in our case, there are a
few patients reported in the literature who
have positive antibodies along with positive
antibodies in CSF.
For the diagnosis of transverse myelitis, MR
imaging is one of the most reliable methods.
MR imaging findings correlate with the
development, grading and the prognosis of
the disease. Nevertheless, it should be
kept in mind that MR imaging is not so
helpful in differentiation of the many causes
of inflammatory myelopathy.
The role of antibiotic therapy in the treatment
of M. pneumoniae-associated myelitis remains
undefined because of unsatisfactory knowledge
regarding the pathogenesis and natural
history of the disease and of controlled trials
assessing such therapy. Antibiotic therapy
has been temporally associated with clinical
improvement in some cases of M. pneumoniaeassociated
acute transverse myelitis. It should
be kept in mind that some patients could
improve completely and spontaneously without
antibiotics. Although macrolides are regarded
as first choice in M. pneumoniae infections, the
fact that they can not penetrate the blood
brain barrier is an important disadvantage of
these drugs. Azithromycin, which can pass the
blood brain barrier, is an agent that should
be preferred in children younger than eight
years old and ciprofloxacin in adults. In
addition, although immune modulators such as
steroids[7,6,17], azathioprine, IVIG and plasma
exchange[7,16] were used in treatment, their role
still remains to be defined.
Although it was not clear whether or not
rapid improvement of our patient was
associated with antimicrobial treatment, we
suggest anti-microbial therapy in cases with
suspected mycoplasma infections associated
with transverse myelitis. In conclusion,
M. pneumoniae should be considered in the
differential diagnosis of patients who have
CNS findings associated with fever and cough
and should be investigated with serological,
molecular and culture methods.
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