254 Mycoplasma pneumoniae infections with atypical development in children – case presentation

Abstract

<h3>Introduction</h3> Lower respiratory tract infections are considered a common cause responsible for morbidity and mortality among children, and Mycoplasma pneumoniae is identified to be responsible for up to 40 per cent of community-acquired pneumonia in children greater than five years of age [1] and also in 20% of adult cases [2]. Extrapulmonary manifestations have been reported either due to spread of infection or autoimmune mechanisms [1]. A case report on necrotizing pancreatitis was issued by Yang et al., 2015 [3]. Case 1. A 9-year old boy was admitted to our hospital presenting with an acute febrile illness lasting for four days associated with a generalised, centripetal rash and macrohaematuria. He had been previously treated with azythromycin for three days. Past medical history revealed that tonsillectomy was performed at 5 years of age and the diagnosis of hypoacusis perceptiva was made. On initial assessment he apeared well, alert and conscious. He was subfebrile (37.6°C). with a maculopapular confluented rash on the trunk and proximal parts of lower limbs. Initial investigation revealed elevated sedimentation rate (54 mm/h), leukocytosis (16,7 x10^9/L), normal hemoglobin level and normal total red cell count. The patient had slightly elevated bilirubin (total bilirubin 65.8, conjugated 44.6 μmol/L), elevated AST (342 U/L), ALT (345 U/L), and GGT (534 U/L). His renal function and electrolyte panel was normal. Chest X-ray was normal without any lesions in the lungs. Urine investigation revealed macrohematuria, proteinuria with active urinary sediment (dismorfic erythrocytes and erythrocyte casts). On ultrasound kidneys were enlarged with hyperechogenic parenchyma, diminished corticomedular differentiation. Because of proteinuria (total protein 2829 mg/24 hours, albumin 1394 mg/24 hours), and hematuria, kidney biopsy was performed. On light microscopy we found mesangihypercellurality, interstitial fibrosis and tubular atrophy (focal). On IF microscopy there was a poorly expressed granular deposit of IgM on the glomerular basement membrane (GBM) with no IgA, IgG, C1q, C3 and C4 immune deposits. On electron microscopy the GBM was of variable width (113 to 670 nm, average 303 nm, SD 164). In the thicker part of GBM lamelation was present. Podocytes were normal. The pathohystologic exam was consistent with Alport syndrome. Mycoplasma serology was consistent with acute infection, with Mycoplasma IgM positive (26.3 U/mL), and negative IgG. Case 2. A 15-year old male adolescent was admitted to hospital with symptoms of abdominal pain lasting for two weeks, with no nausea or vomiting, and normal stool passing. The boy was living with his mother, who had been diagnosed with neurofibromatosis, in an atypical family situation of divorced parents. Physical examination showed abdominal pain in the left upper quadrant, also spreading to the back and lumbar region. Initial laboratory analysis showed a slight increase in serum amylase (140 U/L) and lipase (518 U/L). The C-reactive protein was inside referent range (2 mg/L) as were the value of liver enzymes (AST, ALT, GGT). The TSH was inside referent range, and the antibodies related to gluten enteropathy came negative (anti-tTg-IgA and anti-DGP-IgG). The serology results showed positive antibodies to Mycoplasma pneumoniae (IgM positive, 60.3 U/ml, IgG positive, 25.8 U/ml). We also proved positive IgG antibodies to parvovirus B19, cytomegalovirus, and herpes simplex virus (HSV 1/2). MRI of the abdomen showed a focal pancreatitis (changed signal of the pancreas tail parenchyma). The patient received standard treatment (pancreatic diet and proton-pump inhibitor) and an improvement was perceived with a slow decrease of serum amylase and lipase. Due to a later onset of fever with respiratory symptoms, clarithromycin therapy was initiated. This patient had a second episode of acute pancreatitis nine months after the described event with somewhat larger initial values of serum amylase (154 U/L) and lipase (1533 U/L), and also elevated urine sample values. The patient had reccurent problems with social functioning, which manifested as intermittent palpitations, precordial sensations, and a prolonged episode of large amplitude incontrollable tremor for which he was hospitalized once again after the second episode of pancreatitis. <h3>Conclusion</h3> The presented cases show the possible extent of extrapulmonary illness caused by Mycoplasma pneumoniae in children. Judging by these cases, autoimmune mechanisms and also genetic factors seem to play an important role in the infection of a specific organ by M. pneumoniae.