Case Report:
A six year old girl, who was pre-morbidly well, presented to our emergency department on day 6 of illness. She presented with high grade intermittent fever for 6 days associated with periumbilical abdominal pain, non-bilious vomiting and loose stools for a day. There was history of mild cough since day 3 of illness. There was no other associated systemic symptoms.
She was febrile and tachypneic at presentation, with signs of compensated shock. Her Q-SOFA score was three, indicating severe illness. She was resuscitated with intravenous crystalloids, oxygen and inotropes. She was started on intravenous antibiotics after obtaining blood for aerobic culture. Her abdominal examination revealed mild hepatomegaly and her other systemic examinations were normal. She was admitted in our Paediatric intensive care unit. Infectious causes like Severe sepsis / Enteric fever / scrub typhus with features of compensated shock were differentials considered clinically.
Her initial investigations revealed mild normocytic normochromic anemia, leucopenia, thrombocytopenia with other cell lines in normal limits. Peripheral smear was suggestive of same with no abnormal cells. Her liver function test revealed very high liver enzymes with normal bilirubin level, mild hypoalbuminemia and bleeding parameters were deranged. Her renal function test was normal. CRP was very high suggestive of severe sepsis. Chest xray revealed peri-hilar infiltrates more on right side suggestive of pneumonia.
In view of Pneumonia with hepatitis, anemia, leucopenia, thrombocytopenia and coagulopathy, other differentials like Sepsis with DIC / Swine flu (H1N1) / Leptospirosis/ SLE with autoimmune hepatitis were considered. She was supported with adequate antibiotics, antiviral, blood products and adequate hepato-supportive measures. Her etiological workup were negative for Dengue , leptospirosis, scrub typhus and Swine flu. Autoimmune workup were also negative. Secondary Hemophagocytosis were considered in view of persistent bicytopenia, fever & hepatitis, however workup were negative.
Her liver enzymes were very high initially, gradually reduced from day 4 of hospitalisation after adequate hepato-supportive measures. Her coagulopathy was corrected gradually. Anemia was corrected with packed cell transfusion. However in view of persistent thrombocytopenia, persistent fever, oxygen dependency and poor clinical response to higher antibiotics, Atypical organisms were considered. Anti- Mycoplasma IgM was strongly positive. She was hence started on intravenous azithromycin.
Her clinical and laboratory progress were so good and drastic. She was gradually weaned off from oxygen. Her blood counts, liver function and bleeding parameters were documented in normal limits. She was discharged on day nine of hospitalisation. She was doing well on her follow up.
Discussion:
Mycoplasma , the smallest free-living microorganisms are ubiquitous in nature. Of this group, seventeen have been identified as human pathogens. Mycoplasma pneumoniae, Mycoplasma hominis, and Ureaplasma urealyticum found to cause disease frequently in children. M. pneumonia ferments carbohydrates and requires sterol for growth. It grows under both anaerobic and aerobic conditions, but growth is more consistent when it is incubated in nitrogen and 5 percent carbon dioxide. When compared with other mycoplasmas isolated from humans, M. pneumoniae grows relatively slowly, with visible formation of colonies rarely occurring in less than 1 week and possibly taking 3 weeks or more.
M. pneumoniae affects respiratory system commonly, however there numerous extra-pulmonary manifestations were documented. Pulmonary and extrapulmonary manifestations were tabulated below (table-1). Gastrointestinal manifestations including hepatitis, acute acalculous cholecystitis, and pancreatitis have been reported. Elevated liver enzymes are rarely observed during M. pneumoniae infection in children. Liver involvement was transitory in these patients, and recovery of liver enzymes to normal range correlated directly with resolution of mycoplasma pneumonia, as demonstrated in our patient.
| Pulmonary | Cardo Vascular | Skin | Blood | Gastro- Intensinal | CNS | Musculo- Skeletal |
| Pharyngitis | Pericarditis | Macuopapular rash | Hemolytic anemia | Hepatitis | Aseptic meningitis | Polymyositis |
| Otitis media | Pericarditis | Steven Johnson syndrome | Thrombocytopenia | Cholecystitis | Rye-like illness | Rhabdomyoy-sis |
| Croup | Secondary heart block | Vesicobulous lesion | Disseminated Intravascular coagulation | Splenic infarct | Cerebral Infarct | Leucocytoclastic vasculitis |
| Bronchitis | Erythema multiformae | Secondary heophagocyt-osis | Psychosis | |||
| Infectious asthma | Urticaria | Radiculopathy | ||||
| Pneumonia | Blotchy erythema | ADEM | ||||
| varicella like lesions |
Mycoplasma can be detected easily by cold agglutinin method, detection of IgM / IgA antibodies by ELISA method and also polymerase chain reaction method. Azithromycin and clarithromycin both are approved for the treatment of community-acquired pneumonia and severe disease in children. In more serious illness such as Stevens-Johnson syndrome and neurologic disease, individual case studies have indicated little evidence of therapeutic benefit with either erythromycin or tetracycline therapy. Corticosteroids have been used in severe conditions like steven Johnson, neurological manifestation, severe pneumonia and hemolytic anemia.
Conclusion:
Hence we report a case of Severe mycoplasma pneumoniae infection with atypical manifestations- severe pneumonia associated with hepatitis, thrombocytopenia and coagulopathy, who recovered well with adequate intravenous azithromycin therapy. We conclude that Mycoplasma infection should be considered as differential in atypical extrapulmonary clinical manifestations as listed above.