Mycoplasma pneumoniae infection may cause striatal lesions leading to acute neurologic dysfunction

Autoimmune Movement Disorders in Children

Over the last decade, there have been significant advances in the identification, characterization, and treatment of autoimmune neurologic disorders in children. Many of these diseases include a typical movement disorder that can be a powerful aid to diagnosis. Frequently, movement disorders in autoimmune conditions are the sole or among a few presenting symptoms, allowing for earlier diagnosis of an underlying malignancy or systemic autoimmune disease. Given that early detection and treatment with immunotherapy may confer improved outcomes, recognizing these patterns of abnormal movements is essential for child neurologists. The purpose of this review is to summarize the clinical characteristics, diagnosis, and treatment of movement disorders that occur in pediatric autoimmune disorders.

Mycoplasma pneumoniae from the Respiratory Tract and Beyond

Mycoplasma pneumoniae is an important cause of respiratory tract infections in children as well as adults that can range in severity from mild to life-threatening. Over the past several years there has been much new information published concerning infections caused by this organism. New molecular-based tests for M. pneumoniae detection are now commercially available in the United States, and advances in molecular typing systems have enhanced understanding of the epidemiology of infections. More strains have had their entire genome sequences published, providing additional insights into pathogenic mechanisms. Clinically significant acquired macrolide resistance has emerged worldwide and is now complicating treatment. In vitro susceptibility testing methods have been standardized, and several new drugs that may be effective against this organism are undergoing development. This review focuses on the many new developments that have occurred over the past several years that enhance our understanding of this microbe, which is among the smallest bacterial pathogens but one of great clinical importance.

Transient parkinsonism following mycoplasma pneumoniae infection with normal brain magnetic resonance imaging (MRI)

Parkinsonism caused by infection is uncommon in children. We report 2 previously healthy children with acute self-limiting parkinsonism following Mycoplasma pneumoniae infection, with normal brain magnetic resonance imaging (MRI). Our case report expands the phenotype of parkinsonism associated with M. pneumoniae infection. We recommend that children with acute parkinsonism preceded by a period of febrile illness, even with a normal brain MRI, should be investigated for M. pneumoniae infection.

MR differential diagnosis of acute deep grey matter pathology in paediatric patients

A high metabolic demand, rich vascularization and high concentrations of ionic elements leading to the generation of oxygen free radicals, give to the deep grey matter (DGM) nuclei specific susceptibility to both acute and chronic insults, especially in paediatric patients. Reaching a diagnosis in the early stages of acute diseases in many patients is crucial for instigating prompt specific therapy leading to a favourable outcome. On the basis of a review of a 10-year in-house database and a review of the literature on CNS pathology involving the DGM nuclei in paediatric patients, we summarize the MR findings and clinical clues that may help the radiologist in the difficult differential diagnosis process. The terms "acute" and "chronic" refer to the clinical onset of the disease. MR imaging allows the detection of an injury, determination of its precise anatomical location and characterization of the signal changes. This, combined with a knowledge of specific MRI patterns, may be a roadmap to a definite diagnosis. Clinical history, physical and laboratory findings, timing of the MR examination and advanced MR imaging techniques (diffusion-weighted imaging and (1)H-MR spectroscopy), are crucial in some patients.

Combined Striatum, Brain Stem, and Optic Nerve Involvement due to Mycoplasma pneumoniae in an Ambulatory Child

In children, Mycoplasma pneumoniae encephalitis has been characterized by acute onset of an encephalopathy associated with extrapyramidal symptoms and symmetric basal ganglia with or without brain stem involvement on magnetic resonance imaging. Our case, showing unilateral optic neuritis, ophthalmoplegia, no extrapyramidal symptoms, and typical striatal involvement on magnetic resonance imaging, broadens the spectrum of varying clinical manifestations of childhood M. pneumoniae-associated encephalopathy.

Pathogenesis of neurologic manifestations of Mycoplasma pneumoniae infection

Mycoplasma pneumoniae has been associated with various neurologic manifestations, but exactly how the organism can cause such a wide variety of diseases is a long-standing mystery. In this respect, although pneumonia has been considered the hallmark of Mycoplasma pneumoniae infection, emerging accumulations of data have revealed that the infection can cause a number of extrapulmonary manifestations even in the absence of pneumonia. The importance of host immune response in the pathomechanism of pneumonia has been established, but the pathomechanisms of extrapulmonary manifestations remain largely unknown. For this review, extrapulmonary manifestations due to M. pneumoniae infection were classified into three categories: a direct type, in which locally induced cytokines must play a role; an indirect type, in which immune modulation such as autoimmunity must play a role; and a vascular occlusion type, in which vasculitis or thrombosis (either or both, and with or without systemic hypercoagulable state) must play a role. This classification was then applied within a literature review for neurologic manifestations. Most neurologic manifestations due to M. pneumoniae infection could be reasonably classified into and explained by one of the three types of pathomechanisms.

Infantile bilateral striatal necrosis associated with human herpes virus-6 (HHV-6) infection

A 1-year-old female with acute bilateral striatal necrosis secondary to exanthema subitum associated with human herpesvirus 6 (HHV-6) infection is reported. The patient was previously healthy. She presented with progressive neurologic signs of oral dyskinesia and involuntary movements, after suffering from exanthema subitum. Initial magnetic resonance imaging (MRI) demonstrated abnormal signals in the bilateral striatal regions. In addition, the serum HHV-6 IgM class antibody level was significantly increased. The patient is thought to be the first case of HHV-6 infection related infantile bilateral striatal necrosis (IBSN).

Central nervous system manifestations of Mycoplasma pneumoniae infections

Mycoplasma pneumoniae infection is associated with several manifestations from the central nervous system (CNS) such as encephalitis, aseptic meningitis, acute transverse myelitis, stroke, and polyradiculopathy. In the current paper epidemiologic, clinical, laboratory and treatment data on these manifestations are reviewed. The M. pneumoniae induced immune dysregulation and its contributing role in the pathogenesis of neurological insult is discussed. The recent introduction in clinical practice of newer molecular diagnostic techniques has helped in establishing a firmer association between M. pneumoniae infection and CNS disease especially encephalitis. Clinicians should be aware of the potential association between M. pneumoniae infection and several CNS manifestations. The role of various anti-microbial or immunomodulating therapies in treating such manifestations should be further explored.

Acute disseminated encephalomyelitis presenting with bilateral transient amaurosis

A 4-year-old male presented with acute disseminated encephalomyelitis with seizures and transient amaurosis after initial symptoms of a flulike febrile infection 1 week earlier. Immunoglobulin M type antibody titers against Mycoplasma pneumoniae were significantly increased in serum and cerebrospinal fluid. The patient improved appreciably on immunosuppressive therapy with immunoglobulin. This patient exemplifies a rare case of acute disseminated encephalomyelitis presenting with bilateral transient amaurosis as a complication of M. pneumoniae infection. Aydin A, Atasever S, Cakmakci H. Acute disseminated encephalomyelitis presenting with bilateral transient amaurosis.

Mycoplasma pneumoniae infection and Tourette's syndrome

An association between infection and Tourette's syndrome (TS) has been described repeatedly. A role for streptococcal infection (PANDAS) has been established for several years, but the involvement of other infectious agents such as Borrelia Burgdorferi or Mycoplasma pneumoniae has only been described in single case reports. We examined antibody titers against M. pneumoniae and various types of antibodies by immunoblot in patients and in a sex- and age-matched comparison group. Participants comprised 29 TS patients and 29 controls. Antibody titers against M. pneumoniae were determined by microparticle agglutination (MAG) assay and confirmed by immunoblot. Elevated titers were found in significantly more TS patients than controls (17 vs. 1). Additionally, the number of IgA positive patients was significantly higher in the TS group than in the control group (9 vs. 1). A higher proportion of increased serum titers and especially of IgA antibodies suggests a role for M. pneumoniae in a subgroup of patients with TS and supports the finding of case reports implicating an acute or chronic infection with M. pneumoniae as one etiological agent for tics. An autoimmune reaction, however, has to be taken into account. In predisposed persons, infection with various agents including M. pneumoniae should be considered as at least an aggravating factor in TS.

Diagnosis, treatment, and prognosis of Mycoplasma pneumoniae childhood encephalitis: systematic review of 58 cases

Most of the knowledge on Mycoplasma pneumoniae encephalitis in children is based on case reports or small case series. The aim of this study was to assess the important features of the disease by a systematic review of previously published cases. Overall, 58 cases (22 female, 36 male; median age 10 years, range: 2-17 years), derived from 38 reports, were reviewed. Forty-five patients (76%) had flulike or respiratory symptoms prior to the onset of neurologic disease, and 23 patients (40%) presented with pulmonary infiltrates. Cerebrospinal fluid (CSF) pleocytosis (mostly mononuclear cells) and elevated cerebrospinal fluid protein counts were present in 34 (59%) and 21 (36%) patients, respectively. Cranial computed tomography (CT) or magnetic resonance imaging (MRI) abnormalities were seen in 18 (31%) and 17 (29%) patients, respectively, whereby various different presentations were observed. Forty-four patients (76%) received antimicrobial therapy active against mycoplasmas, most frequently erythromycin (n = 29) or minocycline (n = 6). Only in one patient, cure was directly attributed to antimicrobial therapy (with chloramphenicol) by the respective authors. Thirty-three patients (57%) recovered without sequelae, 20 patients (34%) had minor to major sequelae, and 5 patients (9%) died. A high cerebrospinal fluid cell count, cerebrospinal fluid protein elevation, and higher age were associated with an unfavorable outcome.

Three cases of central nervous system complications associated with Mycoplasma pneumoniae

We report three new cases of acute central nervous system disease occurring shortly after Mycoplasma pneumoniae infection. The clinical phenotypes were characterized by encephalopathy (n = 2), optic neuritis (n = 1), transverse myelitis (n = 1), and seizures (n = 1). Although there was strong supportive evidence of preceding M. pneumoniae infection, cerebrospinal fluid polymerase chain reaction for M. pneumoniae was negative in all three patients. We propose that these cases resulted from a para-infectious immune-mediated process rather than parenchymal invasion by the microorganism. The two patients treated with steroids improved rapidly, and all three patients have made a full recovery. We review the literature regarding M. pneumoniae central nervous system complications and discuss the proposed pathologic mechanisms; para-infectious immune-mediated disease and parenchymal invasion of the central nervous system. Systematic investigation to discriminate between these two processes will be essential to select appropriate antibiotic and immunomodulatory therapies.

Diagnostic approach in patients with symmetric imaging lesions of the deep gray nuclei

BACKGROUND

Selective insult to brain deep gray matter nuclei is uncommon, may be congenital or acquired, acute or chronic, and varied in etiology. Determining the etiology relies on history, clinical presentation, laboratory investigations, and lesion pattern on Neuroimaging.

REVIEW SUMMARY

We review the differential diagnosis and clinical, laboratory and neuroimaging pattern of conditions that manifest with lesions of deep gray matter nuclei in the context of representative case studies.

CONCLUSION

While presentations may vary in individual patients, the essentials of history, clinical examination, laboratory evaluation,and neuroimaging lesion pattern can be efficiently directed to differentiate the various etiologies of deep gray matter nuclei lesions. In this review we focus on the etiologic classification and diagnostic approach to acute and chronic conditions that manifest on neuroimaging with bilateral symmetric lesions of deep gray matter nuclei.

Mycoplasma pneumoniae ecephalitis

Mycoplasma pneumoniae causes between 5 and 10 percent of acute childhood encephalitis in Europe and North America. Encephalitis due to this organism may be caused by direct infection of the brain, immune-mediated brain injury or thromboembolic phenomenon. The prognosis is guarded with 20 to 60 percent suffering neurologic sequelae. The diagnosis of M. pneumoniae encephalitis should be based on strong evidence of M. pneumoniae infection that includes detection of the organism in culture or using molecular detection techniques in addition to serology and exclusion of other potential etiologies. Antibiotic therapy should be considered for all children with suspected M. pneumoniae encephalitis; antibiotics with good central nervous system (CNS) penetration such as ciprofloxacin, doxycycline, chloramphenicol or azithromycin are appropriate under most circumstances. Immune modulating therapies, such as corticosteroids, intravenous immune globulin or plasmapharesis, should be considered in those with immune-mediated syndromes such as acute disseminated encephalomyelitis.

Treatment of dystonia in striatal necrosis caused by Mycoplasma pneumoniae

We report on an 8-year-old male with bilateral striatal necrosis secondary to Mycoplasma pneumoniae respiratory infection. This patient has been remarkable for persistent severe dystonia that has been difficult to treat. We share our experience of beneficial responses to multimodal treatment, including moderate doses of trihexyphenidyl, botulinum toxin, and intrathecal baclofen.

Brainstem and striatal encephalitis complicating Mycoplasma pneumoniae pneumonia: possible benefit of intravenous immunoglobulin

Encephalitides of the brainstem and the striatum associated with Mycoplasma pneumoniae infection are believed to be mediated by an autoimmune process triggered by the organism, a toxin or direct invasion by the organism itself. Inability to identify M. pneumoniae from cerebrospinal fluid by culture or polymerase chain reaction suggested a possible immunologic process. A trial of intravenous immunoglobulin in a critically ill patient with encephalitis that developed in parallel to M. pneumoniae pneumonia was associated with neurologic improvement within 48 h of treatment.

Transient seizure disappearance due to bilateral striatal necrosis in a patient with intractable epilepsy

An 8-year-old girl had suffered from intractable epilepsy due to cortical dysplasia. She developed mycoplasma pneumonia with massive pleural effusion. Fever continued for 3 weeks. Four weeks after the onset of this infection, she suddenly developed horizontal nystagmus, ataxia, choreoathetotic movements and confusion. CT disclosed swelling and low density of the heads of the caudate nuclei and putamina bilaterally. MRI revealed areas of symmetrical high intensity in the striatum on T2-weighted imaging. These lesions were thought to comprise bilateral striatal necrosis (BSN) mediated by the mycoplasma infection or Wernicke encephalopathy. Six months later, she had completely recovered clinically. During the 6 months after BSN, she did not have any epileptic seizures. Her epileptic seizures reappeared thereafter at a lower frequency. The striatum may be involved in the propagation pathway for epileptic seizure activity in this patient.

[Mycoplasma pneumoniae meningoencephalitis]

BACKGROUND

Severe central nervous system diseases, such as encephalitis, have been reported in association with Mycoplasma pneumoniae infections.

CASE REPORT

After an ENT infection, a 9-year-old boy with Down's syndrome developed encephalitis revealed by an acute alteration in consciousness. Head computed tomography showed, after 2 weeks, an infiltration in the basal ganglia region. The diagnosis of Mycoplasma pneumoniae encephalitis was made; recovery was complete in a few weeks.

CONCLUSION

Mycoplasma pneumoniae infection should be considered in all cases of acute encephalopathy; yet the pathogenesis of the disorder is unknown and the treatment uncertain.

Reversible parkinsonism and dystonia following probable mycoplasma pneumoniae infection

Infectious disease is a rare cause of parkinsonism. We report a 7-year-old boy who developed flu-like symptoms followed by parkinsonian features including hypophonia, hypomimia, bradykinesia, and dystonia. A T2-weighted brain magnetic resonance imaging showed high signal intensities in both basal ganglia. The results of serial serologic tests of Mycoplasma pneumonia antibody suggest that this movement disorder was associated with Mycoplasma pneumonia infection. The patient's symptoms gradually resolved, and the basal ganglionic lesions disappeared on follow-up magnetic resonance imaging.