Carditis associated with mycoplasma pneumoniae infection

Hypotension associated with azithromycin infusion in children with heart failure: a case report

We report two cases of acute hypotension after intravenous azithromycin administration in children with acute, decompensated heart failure. In each of our reported cases, azithromycin was being used to treat possible Mycoplasma myocarditis. In this report, we aim to describe hypotension as a potentially rare adverse reaction to intravenous azithromycin and encourage judicious use in patients with cardiac dysfunction.

Chest pain in adolescent Japanese male mimicking acute coronary syndrome

Acute chest pain with very elevated troponin level and abnormal EKG in adult population is considered sine qua non to acute coronary syndrome (ACS) unless proved otherwise. Similar presentation in adolescent population is seen less often but raises suspicion for ACS. Most common etiology for chest pain with cardiac enzyme elevation in adolescent population is usually viral myopericarditis. The adolescent population presenting with chest pain and elevated cardiac enzymes should be carefully evaluated for ACS and other etiologies including myocarditis, myopericarditis, pulmonary embolism, acute rheumatic fever, and trauma. We report one Japanese adolescent male with mycoplasma pneumoniae myocarditis who presented to the ER with chest pain, elevated cardiac enzymes, and abnormal EKG.

Age-specific Mycoplasma pneumoniae pneumonia-associated myocardial damage in children

OBJECTIVE

To measure Mycoplasma pneumoniae pneumonia (MPP)-associated myocardial damage in different age groups of children with pneumonia.

METHODS

Children aged 0-14 years with pneumonia and myocardial damage (serum creatine kinase isoenzyme-MB [CK-MB] concentration >25 U/l) were enrolled in the study. The children were classified as Mycoplasma pneumoniae immunoglobulin M positive (M. pneumoniae IgM+) or negative (M. pneumoniae IgM-) based on a serological test. Children were stratified into four age groups in order to analyse age-specific MPP-associated myocardial damage.

RESULTS

The incidence of fever was significantly higher in children who were M. pneumoniae IgM+ compared with M. pneumoniae IgM- children. The median serum CK-MB concentration was significantly higher in children who were M. pneumoniae IgM+ compared with those who were M. pneumoniae IgM-. Children who were M. pneumoniae IgM+ in the 13-36 months and 72 months-14 years age groups had significantly higher median serum CK-MB concentrations than those who were M. pneumoniae IgM- in the same age group.

CONCLUSIONS

M. pneumoniae infection was associated with greater myocardial damage in children aged 13-36 months and 72 months-14 years. This suggests age-specific immune responses to M. pneumoniae.

A case of acute myopericarditis associated with Mycoplasma pneumoniae infection in a child

Mycoplasma pneumoniae (M. pneumoniae) primarily causes respiratory tract infections in persons aged 5-20 years. Tracheobronchitis and bronchopneumonia are the most commonly recognized clinical symptoms associated with M. pneumoniae infection. Complications of this infection are unusual; in particular, cardiac involvement is very rare and is generally accompanied by pneumonia. Nonrespiratory illness can therefore involve direct invasion by M. pneumoniae or autoimmune mechanisms, as suggested by the frequency of cross reaction between human antigens and M. pneumoniae. Herein, we report a case of severe acute myopericarditis with pneumonia caused by M. pneumoniae in a healthy young child who presented with fever, lethargy, oliguria and dyspnea. She survived with aggressive therapy including clarithromycin, intravenous immunoglobulin, inotropics, and diuretics. The patient was discharged on the 19th day after admission and followed up 1 month thereafter at the outpatient clinic without sequelae.

Mycoplasma pneumoniae Associated with Hemolytic Anemia, Cold Agglutinins, and Recurrent Arterial Thrombosis

A 40-year-old white male developed Mycoplasma pneumoniae pneumonia (IgM titer 1:256) as well as autoimmune hemolytic anemia due to cold agglutinins (titer of 1:512). Four days after admission to the hospital, he developed an acute superior mesenteric artery (SMA) thrombosis. Four feet of ischemic small bowel were resected. A follow-up angiogram again showed SMA thrombosis and a left popliteal artery thrombosis. The patient was returned to the operating room and underwent thrombectomy of the affected arteries. The following day, he again developed a left popliteal artery thrombosis requiring thrombectomy. Plasmapheresis, Coumadin and prednisone were implemented. No further thrombotic events occurred. Hypercoagulability workup was negative. Pathology samples revealed vasculitis. Based on a negative hypercoagulability workup, nonrecurrence of thrombotic events after treatment, and in the absence of any structural abnormalities of the affected arteries, an autoimmune phenomenon with damage to the endothelium was thought to have played a role in the mechanism of thrombosis.

[Extrapulmonary infections due to Mycoplasma pneumoniae]

Pneumonia is the main site of infection with Mycoplasma pneumoniae in paediatric age. Nevertheless it can also give rise to other manifestations, with or without respiratory involvement. In the present review are described some unusual clinical features of M. pneumoniae in children. Encephalitis and meningoencephalitis is the most frequent neurological manifestation, but cases of meningitis, myelitis, and polyradiculitis, have been reported. Cardiac involvement is potentially severe, including pericarditis and myocarditis. Cold agglutinin haemolytic anaemia is the most frequent haematologic manifestation. Skin, renal, gastro-intestinal, osteoarticular, and other manifestations have also been reported in the literature. The pathogeny of these extrapulmonary infections is not fully elucidated and the treatment remains partly controversial. Extrapulmonary complications can occur as a result of direct invasion and/or autoimmune response.

Mycoplasma pneumoniae and its role as a human pathogen

Mycoplasma pneumoniae is a unique bacterium that does not always receive the attention it merits considering the number of illnesses it causes and the degree of morbidity associated with it in both children and adults. Serious infections requiring hospitalization, while rare, occur in both adults and children and may involve multiple organ systems. The severity of disease appears to be related to the degree to which the host immune response reacts to the infection. Extrapulmonary complications involving all of the major organ systems can occur in association with M. pneumoniae infection as a result of direct invasion and/or autoimmune response. The extrapulmonary manifestations are sometimes of greater severity and clinical importance than the primary respiratory infection. Evidence for this organism's contributory role in chronic lung conditions such as asthma is accumulating. Effective management of M. pneumoniae infections can usually be achieved with macrolides, tetracyclines, or fluoroquinolones. As more is learned about the pathogenesis and immune response elicited by M. pneumoniae, improvement in methods for diagnosis and prevention of disease due to this organism may occur.

Enterovirus, mycoplasma and other infections as predictors for myocardial infarction

OBJECTIVES

To study antibodies against five infectious agents for their prediction of major coronary events in men with and without evidence of coronary heart disease at baseline.

DESIGN

A case-control study nested within a prospective population study.

SUBJECTS

The study cases included 441 men 45-64 years old with nonfatal myocardial infarction or coronary death within a mean follow-up time of 10 years. A total of 165 men had already signs of heart disease at baseline, whilst 276 were apparently healthy at the beginning of the study. Two controls for each case were matched for age, heart disease status and place of residence. Antibodies against enterovirus, Mycoplasma pneumoniae, Chlamydia pneumoniae, cytomegalovirus and adenovirus were determined.

RESULTS

Men without reported baseline heart disease, but not those with heart disease, showing the highest quartile of antibodies to enterovirus and mycoplasma or increased levels of immune complex-bound antibodies to chlamydia had a significantly higher risk of coronary events than men with lower level of antibodies. The increased risk demonstrated in men with high levels of antibodies to enterovirus and mycoplasma remained significant after adjustment for other antibodies, acute-phase reactant and conventional risk factors. Serological evidence of infection by multiple agents was also significantly associated with coronary events.

CONCLUSIONS

Serological evidence for several infectious agents is associated with the risk of coronary heart disease, but only in men without baseline history of heart disease.

Life-threatening Mycoplasma hominis mediastinitis

Mycoplasma hominis infections are easily missed because conventional methods for bacterial detection may fail. Here, 8 cases of septic mediastinitis due to M. hominis are reported and reviewed in the context of previously reported cases of mediastinitis, sternum wound infection, pleuritis, or pericarditis caused by M. hominis. All 8 patients had a predisposing initial condition related to poor cardiorespiratory function, aspiration, or complications related to coronary artery surgery or other thoracic surgeries. Mediastinitis was associated with purulent pleural effusion and acute septic symptoms requiring inotropic medication and ventilatory support. Later, the patients had a tendency for indolent chronic courses with pleuritis, pericarditis, or open sternal wounds that lasted for several months. M. hominis infections may also present as mild sternum wound infection or as chronic local pericarditis or pleuritis without septic mediastinitis. Treatment includes surgical drainage and debridement. Antibiotics effective against M. hominis should be considered when treating mediastinitis of unknown etiology.

Misdiagnosis of post-traumatic splenic rupture in a patient with acute cold agglutinin disease due to Mycoplasma infection

We describe a case of cold agglutinin disease, secondary to Mycoplasma pneumoniae infection, which presented with anaemia and abdominal pains in apparent succession to a thoraco-abdominal trauma. An exploratory laparotomy, carried out because of suspected post-traumatic rupture of the spleen, was complicated by a transitory cardiorespiratory arrest. The subsequent and correct diagnosis of the mycoplasmal infection and the cold agglutinins led to specific and successful therapy. The previously unknown hypertrophic cardiomyopathy was a contributing factor to the cardiorespiratory arrest.

Advanced atrioventricular block associated with atrial tachycardia caused by Mycoplasma pneumoniae infection

Atrial tachycardia with atrioventricular (AV) block has been recognized as a common manifestation of digitalis toxicity. We describe here an unusual case of transient advanced AV block associated with atrial tachycardia in a 6 year old boy with evidence of Mycoplasma pneumoniae infection.

Mycoplasma pneumoniae infection associated with central nervous system complications

We describe two children who had central nervous system complications, encephalitis and meningoencephalitis, temporally associated with Mycoplasma pneumoniae. M pneumoniae was identified as the cause of the illnesses on the basis of at least a fourfold increase in complement fixation antibody titers. Despite extensive viral and bacterial investigation, no evidence of any other pathogen was found. Two strategies were used to determine whether M pneumoniae was directly invasive: (1) by examining cerebrospinal fluid using a M pneumoniae-specific DNA probe and (2) by determining whether complement-fixating antibody to M pneumoniae was produced locally through comparison of the cerebrospinal fluid/serum ratio of M pneumoniae antibody to the cerebrospinal fluid/serum ratio of immunoglobulin M. Both assessments were negative. M pneumoniae did not appear to directly invade the central nervous system in these two patients. We conclude that the direct invasion of the cerebrospinal fluid is not necessary in the pathogenesis of M pneumoniae-induced neurologic disease.

Complete heart block from mycoplasma pneumoniae infection

Complete heart block (CHB) in infants and children is usually congenital. Nonsurgical acquired CHB is rare. Occasionally, transient acquired CHB is seen in association with viral myocarditis. We describe here an unusual case of transient CHB in a 12-year-old boy with endomyocardial biopsy-proven myocarditis and evidence of Mycoplasma pneumoniae infection.

Prevalence of Mycoplasma pneumoniae in children with pneumonia in Zaria, Nigeria

The prevalence of Mycoplasma pneumoniae in children suffering from pneumonia was investigated, using complement fixation and growth inhibition tests. From the sera of 104 children with pneumonia, 32 (31%) showed a CF titre greater or equal to 1:64, while all the 52 control children of the same age and sex had a CF titre less than 1:16. Children 6-10 years of age had the highest positive titre (41%) while the age groups 3-5 years and 0-2 years had positive titres of 30 and 28%, respectively. Both sexes were equally affected (33% male, 29% female). Mycoplasma pneumoniae was isolated in two children whose CF antibody titres were 1:16. It is concluded that M. pneumoniae plays an important role as an aetiological agent of pneumonia in children in Zaria, Nigeria, and could be included in the routine diagnostic protocol of pneumonia, especially during the dry harmattan months when cases of lobar pneumonia are prevalent.

Arrhythmogenic right ventricular dysplasia in brother and sister: is it related to myocarditis?

Two cases of arrhythmogenic right ventricular dysplasia (ARVD) in siblings are reported. In the boy, 14 years old, the clinical history, ECG, echocardiography, and histopathological findings were consistent with ARVD. Premature ventricular contractions of left bundle branch block (LBBB) pattern were recorded but no ventricular tachycardia (VT). A high titer against mycoplasma and increased concentrations of immunoglobulins were found. Two years after his first admission he died suddenly. Autopsy revealed severe right ventricular (RV) myocardial damage, with fat cell infiltration and collagenous tissue. His sister presented with sustained VT of LBBB pattern 2 years later, at 12 years of age. Vaccination against rubella and signs of upper respiratory illness had preceded the symptoms. During the following 9 days ECGs and serum enzymes indicated the development of left ventricular (LV) infarction. Echocardiography revealed an enlarged RV and a normal LV. After 6 weeks both RV and LV showed akinetic areas and sacculations. We suggest that myocarditis may be a precipitating factor in ARVD, and perhaps the prerequisite for its manifestation.

[Familial Mycoplasma pneumonia. The varied picture of pulmonary and extrapulmonary manifestations]

Mother, father (26 y.o.) and their only child (5 y.o.) developed nonproductive cough, fever (39.5 to 40.4 degrees C) and bilateral pulmonary infiltrates within three weeks. In addition the mother developed a small left pleural effusion and a pericardial effusion, a relative bradycardia, a pruritic vesicular exanthem of the extremities and the trunk, an erythema nodosum and arthritis of the tarsal joints. The father's coulter counter red blood count was distorted by microagglutination at room temperature (hemoglobin 13.2 gr/dl; erythrocytes 1,91 X 10(6) mm-3 and MCH 69.1 pg; MCV 120 fl and hematocrit 23.8%) but not at 37 degrees C (13.2; 4.15 and 31.8; 92 and 39.3, respectively). In the daughter myringitis, pharyngitis, cervical lymphadenopathy and splenomegaly were observed. Cold agglutinins and serologic evidence for mycoplasma pneumoniae infection were demonstrable in all three. Treatment with Tetracycline (parents) and Erythromycin (child) was effective.

Progressive heart failure and death associated with Mycoplasma pneumoniae pneumonia

A case of progressive CHF and death associated with serologically confirmed Mycoplasma pneumoniae pneumonia in a previously healthy man is described. The association between the organism and significant cardiac or pericardial dysfunction discussed, the literature reviewed, and speculation made as to the underlying pathophysiologic mechanisms.

Central nervous system manifestations associated with serologically verified Mycoplasma pneumoniae infection

Among 560 hospitalized patients with serologically verified Mycoplasma pneumoniae infection (significant titre rise of complement-fixing antibodies in paired sera), 27 (4.8%) had central nervous system (CNS) manifestations for which no evidence incriminating any other causal agent could be found. Of these patients 18 had encephalitis or meningoencephalitis, 8 aseptic meningitis and 1 polyradiculitis. Of the patients with meningoencephalitis 4 died and 3 had permanent sequelae. The cases of aseptic meningitis were benign without any deaths or sequelae. There was a predominance of young age groups, 13 patients (48%) being below 10 years of age. Neither erythromycin nor tetracycline had a beneficial effect on the course of the illness in a few patients treated. Another 15 patients had CNS manifestations for which an alternative aetiology was suspected. The specificity of the M. pneumoniae CF test in the diagnostics of CNS manifestations is discussed, as well as the pathogenesis of the CNS complications associated with M. pneumoniae infection. Some features are summarized from 87 case reports presented earlier in the literature.