Conclusion:
Young man with recent Mycoplasma pneumonia
infection presented with an acute ischemic stroke with evidence of CNS
angiitis and no other clear cause can be detected.
Patient received clacid (an antibiotic with good
cover for Mycoplasma spp) and aspirin. He made a tremendous recovery.
Mycoplasma Pneumonia:
Mycoplasma pneumonia
is one of the most common cause of atypical pneumonia in collected series from
the United States and other part of the world. Mycoplasma pneumonia,
Chlamydia, Legionella species have been though to account for
7 to 20% of community acquired pneumonia for which a pathogen can be
identified. However, the incidence may be higher for mild cases that can be
managed without hospitalization. There are no
clinical symptoms, findings, or chest radiograph appearance that reliably
distinguish atypical pneumonia from ather pyogenic
infection. Additional difficulty in making an
etiologic diagnosis in atypical pneumonia is that the pathogen is difficult to
culture and diagnosis relies
on serological tests.
Pathogenesis:
Mycoplasma pneumonia
grows under aerobic and aerobic condition. The organism most commonly exists
in filamentous form and has adherence protein that attach to epithelial
membranes with particular affinity for respiratory tract epithelium. Once
attached, mycoplasma pneumonia produces
hydrogen peroxide and superoxide causing injury to epithelial cells and their
associated cilia. However, many of pathogenic feature of infection with
mycoplasma pneumonia are believed to be immune mediated rather than induced
directly by the bacteria. This immune mediated mechanism supported by the
finding that infant and young children infrequently develops pneumonia despite
evidence of infection.
Epidemiology:
Infection is ttransmitted
from person to person by infected respiratory droplets.
Incubation period average 3 weeks.
Infection usually occurs in fall
and winter seasons. Infection rates are high in
school age children, military recruits and college students. The
attack rates in families approaches 10% and immunity is not long lasting.
Clinical Features:
Many infection due to
mycoplasma pneumonia are asymptomatic.
Onset of illness is gradual and is usually heralded by
headache, malaise and low grade fever. Chills are
frequent but rigors are very rare. Patient
complaints exceed objective findings since abnormalities on physical
examination are Minimal. Clinical manifestation of M. pneumonia
divided into those, due to respiratory tract or extrapulmonary disease.
CNS Manifestation:
Occurs in approximately 0.1 % of all patient with
M. pneumonia and up to 7% of patients requiring hospitalization. CNS
involvement occurs most frequently in children and includes aseptic
meningitis, meningio-encephalitis, peripheral neuropathy, stroke with
angiitis, transverse myelitis, cranial nerve palsy and cerebellar ataxia. In
case of CNS involvement due to mycoplasma pneumonia, a history of an
antecedent infection is usual, but not always found.
Chest Radiography:
Bronchopneumonia, atelactatic changes, nodular
infiltration. Most common is prebronchial pneumonia, with predilection for the
lower lobes. Pleural effusion occurs in 20% and empyma is rare
Diagnosis:
The most used approach for diagnosis is the
complement fixation test (CF) which measure early IgM (predominantly) and IgG
antibody. Four fold increase in titre in paired sera or a single titire of
greater than or equal to 1:32. Major disadvantage of CF test is false positive
results. Antigen detection can be performed by antigen capture enzyme
immunoassay. Direct PCR detects genomic DNA, and may be highly sensitive and
specific for mycoplasma pneumonia.
Specific Mycoplasma Therapy:
Doxycycline 100mg twice a day orally or
erythromycin 333mg three times orally (both are equally effective) for 2
weeks. No studies have been performed to evaluate effectiveness of alternative
therapies in patient with hemolytic anemia or CNS involvement. For CNS disease
therapy with steroid, NSAIDS or plasma exchange have been used in addition to
antibiotics.
Dr. Mohammed Al-Zawahma
Neurology Resident
Neurology Division
Neurosciences Department
Riyadh Armed Forces Hospital
