Internal carotid artery occlusion associated with Mycoplasma pneumoniae infection

The Spectrum of Pediatric Infection-Associated Intracranial Arteriopathies and Acute Ischemic Stroke at 2 Eastern Indian Tertiary Care Centres

INTRODUCTION

Major and minor pediatric infections may cause intracranial arteriopathies, the long-term outcome of which we investigated and identified the factors influencing the progression/resolution of arteriopathies.

METHODS

We collected the clinical and radiological data of children aged 1 month-15 years who had ischemic stroke with definite arteriopathy following a recent febrile infection. Repeated neuroimaging was done over the next year to ascertain recurrent strokes and the progression and resolution of arteriopathies.

RESULTS

The anterior circulation was more frequently affected (83.33%), predominantly involving the middle cerebral artery (41.67%), resolving in 20.84% of cases and progressing in 33.33% of cases. Lesions were commonly unilateral (54.17%) and stenotic (75%), resulting predominantly in cortical infarcts (45.83%), with hemiparesis being the most common neurodeficiency. Apart from tubercular meningitis patients, others had a good functional outcome.

CONCLUSION

Lower age, minor infections, and unilateral arteriopathies had a significantly higher chance of resolution. Postviral arteriopathies had a significantly lower chance of progression compared with those following bacterial infections. Progressive and bilateral arteriopathies were significantly associated with worse outcomes and recurrent strokes.

Thrombosis associated with mycoplasma pneumoniae infection (Review)

Mycoplasma pneumoniae is a common pathogen causing respiratory infections in children and adults. In addition to respiratory diseases, Mycoplasma pneumoniae is also involved in numerous extrapulmonary diseases. Thrombosis is an extrapulmonary manifestation associated with Mycoplasma pneumoniae infection. In recent years, an increasing number of case reports have been published identifying thrombosis secondary to Mycoplasma pneumoniae infection. In the present study, the available relevant literature in English available on PubMed, Medline and Web of Science was consulted. The results of the present study demonstrated that in patients with thrombosis caused by Mycoplasma pneumoniae infection, some of the factors causing thrombosis are transient and some are due to hereditary thrombophilia. Following timely treatment, the majority of patients recovered completely but some patients had a poor prognosis. The present review focuses on the pathogenesis, clinical features, treatment and prognosis of this crucial issue, which contributes toward the understanding of the disease.

Stroke Associated With Recent Mycoplasma Pneumoniae Infection: A Systematic Review of Clinical Features and Presumed Pathophysiological Mechanisms

Introduction: An association between Mycoplasma pneumoniae (MP) infection and stroke has been described, especially in children. However, current knowledge on this rare potential cause of stroke is scant. The purpose of this systematic review of all published cases was to help better understand the relationships between recent MP infection and ischemic stroke on a clinical, radiological and pathophysiological perspective.

Material and Methods: A PubMed and Embase search was performed in September 2018 to identify all published cases of stroke occurring within 4 weeks after MP infection.

Results: Twenty-eight patients with ischemic stroke associated with MP infection were identified. Median age was 8 years (range: neonate to 57). The middle cerebral artery territory was involved in 25 (89%) patients. Fifteen (54%) patients had at least one arterial occlusion. Elevated D-dimer and/or fibrinogen was reported in 8 (29%) patients. Four patients had transient anticardiolipin IgM antibodies. Cerebrospinal fluid analysis showed pleocytosis in 7/20 (35%) patients (median: 19 leucocytes/μL, range: 10 to 63) and MP PCR was positive in 3/8 (38%) patients. The etiological work-up was considered inconclusive in 25 (89%) patients. Three (11%) patients died during follow-up, all of early respiratory deterioration. Neurological functional outcome was good in 22/27 (81%) patients.

Conclusion: The association between MP infection and ischemic stroke in children and young adults is rare. Underlying pathogenesis might include hypercoagulability and vasculitis. Most patients achieve a favorable recovery. Whether MP infection could be a long-term risk factor for stroke by promoting atherosclerosis is uncertain and deserves further investigation.

Extensive and Progressive Cerebral Infarction after Mycoplasma pneumoniae Infection

Acute cerebral infarctions are rare in children, however they can occur as a complication of a Mycoplasma pneumoniae (MP) infection due to direct invasion, vasculitis, or a hypercoagulable state. We report on the case of a 5-year-old boy who had an extensive stroke in multiple cerebrovascular territories 10 days after the diagnosis of MP infection. Based on the suspicion that the cerebral infarction was associated with a macrolide-resistant MP infection, the patient was treated with levofloxacin, methyl-prednisolone, intravenous immunoglobulin, and enoxaparin. Despite this medical management, cerebral vascular narrowing progressed and a decompressive craniectomy became necessary for the patient’s survival. According to laboratory tests, brain magnetic resonance imaging, and clinical manifestations, the cerebral infarction in this case appeared to be due to the combined effects of hypercoagulability and cytokine-induced vascular inflammation.

Complete occlusion of the right middle cerebral artery associated with Mycoplasma pneumoniae pneumonia

We report a case of a 5-year-old girl who developed left hemiparesis and left facial palsy, 6 days after the initiation of fever and respiratory symptoms due to pneumonia. Chest radiography, conducted upon admission, showed pneumonic infiltration and pleural effusion in the left lung field. Brain magnetic resonance imaging showed acute ischemic infarction in the right middle cerebral artery territory. Brain magnetic resonance angiography and transfemoral cerebral angiography revealed complete occlusion of the right middle cerebral artery. Mycoplasma pneumoniae infection was identified by a 4-fold increase in IgG antibodies to M. pneumoniae between acute and convalescent sera by enzyme-linked immunosorbent assay. Fibrinogen and D-dimer levels were elevated, while laboratory exams in order to identify other predisposing factors of pediatric stroke were all negative. This is the first reported pediatric case in English literature of a M. pneumoniae-associated cerebral infarction involving complete occlusion of the right middle cerebral artery.

The Focal Encephalopathies Associated with Mycoplasma Pneumoniae

Five patients with evidence of focal encephalopathy are reported. In each case, evidence of mycoplasma pneumoniae infection was detected. No patient improved with conventional antibiotic therapy, but in three subjects, rapid and complete recovery did occur contemporaneously with the administration of high dose steroid therapy. It is suggested that focal as well as diffuse cerebral or cerebellar lesions may occur as manifestations of auto-immune disease complicating mycoplasmal infections in young people and that this illness may be designated as acute mycoplasma-associated encephalopathy.

Mycoplasma pneumoniae associated stroke in a 3-year-old girl

Infectious diseases precede a significant proportion of acute ischemic strokes in children. Here, we report a case of acute ischemic stroke in a 3-year-old girl with a Mycoplasma pneumonia-associated respiratory tract infection. She developed an acquired prothrombotic state of protein S deficiency and had increased fibrinogen and fibrinogen degradation product levels and increased titer of antinuclear antibodies. However, these conditions were completely alleviated at the 1-month follow-up examination. Infection with M. pneumoniae may cause a transient prothrombotic state that can potentially cause a thrombus.

Aortic thrombus and multiple embolisms during a Mycoplasma pneumoniae infection

We report the case of a patient who presented with a thrombus of the aortic arch complicated with splenic, renal and peroneal artery embolisms, associated with transient lupus anticoagulant, during a Mycoplasma pneumoniae infection. The outcome was good under antibiotic and anticoagulant treatment. We also review the medical literature on M. pneumoniae-related thromboses.

Severe Mycoplasma pneumoniae infection requiring extracorporeal membrane oxygenation with concomitant ischemic stroke in a child

Mycoplasma pneumoniae is one of the most common agents causing respiratory disease in children. The most common extra-pulmonary manifestations of M. pneumoniae include central nervous system involvement, with stroke being an uncommon but devastating consequence. We present a 13-year-old girl with severe respiratory disease requiring extracorporeal membrane oxygenation, who developed ischemic stroke associated with clinical and serologic evidence of M. pneumoniae. A case of M. pneumoniae causing this degree of respiratory failure associated with stroke has not been previously reported. Prompt recognition of severe mycoplasmal infection may allow for earlier treatment and concomitant evaluation of neurologic injury.

Multiple cerebral arterial occlusions related to Mycoplasma pneumoniae infection

We report the case of a 33-year-old man with a brainstem infarction due to concomitant occlusions in the left internal carotid, both vertebral, and basilar arteries. The patient had experienced a severe Mycoplasma pneumoniae infection about 10 months prior to symptom onset, and his Mycoplasma antibody titre was positive when the stroke occurred. Despite performing meticulous neurological, vascular, and medical evaluations, we were unable to detect other possible causes of the stroke. Therefore, the multiple occlusions in the major cerebral arteries of our patient were concluded to be related to M. pneumoniae infection.

Infectious atherosclerosis: is the hypothesis still alive? A clinically based approach to the dilemma

Among the multiple factors involved in the pathophysiology of heart disease, infections have been proposed to play a role in atherosclerosis with most of the available evidence implicating Chlamydia pneumonia, influenza virus and Mycoplasma pneumoniae. Based on a model case presentation, we speculate that in the absence of traditional risk factors and in the context of an ongoing respiratory infection caused by a pro-inflammatory pathogen (M. pneumoniae) along with a past positive serologic history for potentially proven atherogenic microorganism (C. pneumoniae) and infection may elicit potentially pathogenic events on vascular wall cells and leukocytes of atheromatous lesions, supporting the hypothesis that such infections may potentiate atherosclerotic cardiovascular disease (CVD).

Mycoplasma pneumoniae-associated cerebral infarction in a child

The central nervous system's involvement is the most common reported extra-pulmonary manifestations of Mycoplasma pneumoniae infection, and stroke was one of the most special situations. We presented a 4-year-old child who presented with acute stroke on the third day of the onset of Mycoplasma respiratory tract infection. Brain magnetic resonance angiography demonstrated that occlusion of bilateral internal carotid arteries and vertebral arteries above the level of the first cervical vertebrate which is not been reported previously.

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.

Mycoplasma pneumoniae in elderly patients with stroke. a case-control study on the seroprevalence of M. pneumoniae in elderly patients with acute cerebrovascular disease - the M-PEPS Study

BACKGROUND AND PURPOSE

Previous studies have suggested certain infections as potential risk factors for stroke. Chlamydia pneumoniae, an atypical respiratory pathogen, has been linked to atherosclerotic vascular diseases. Mycoplasma pneumoniae, another atypical respiratory micro-organism, can rarely cause stroke. We investigated whether serological markers of M. pneumoniae infection were associated with acute stroke or transient ischaemic attack (TIA) in elderly patients.

METHODS

This case-control study was nested within the C-PEPS study - a case-control study on the seroprevalence of C. pneumoniae in elderly stroke and medical patients. Ninety-five incident cases of patients admitted consecutively with acute stroke or TIA, and 82 control subjects admitted concurrently with acute non-cardiopulmonary, non-infective disorders, were included in this study (both groups aged 65 years or older). Using commercial enzyme-linked immunosorbent assay (ELISA) kits, the presence of M. pneumoniae immunoglobulins IgA, IgG and IgM in patients' sera was determined.

RESULTS

The seroprevalence of M. pneumoniae IgA, IgG and IgM in the stroke or TIA group (median age = 80) were 79, 61 and 6%, respectively. In the control group (median age = 80), the seroprevalence of respective M. pneumoniae IgA, IgG and IgM were 84, 50 and 11%. Using a logistic regression statistical model, adjusting for history of hypertension, smoking, diabetes mellitus, age and sex, history of ischaemic heart disease, and ischaemic electrocardiogram, the odds ratios of having a stroke or TIA in relation to M. pneumoniae IgA, IgG and IgM were 0.63 (95% confidence interval (CI) = 0.26-1.52, p = 0.31), 1.32 (95% CI = 0.66-2.64, p = 0.43) and 0.52 (95% CI = 0.14-1.92, p = 0.32), respectively.

CONCLUSIONS

The study showed a high seroprevalence of M. pneumoniae in an elderly hospital population, using ELISA. Although the study ruled out M. pneumoniae seropositivity as a major risk factor for stroke in this elderly population, a smaller effect could not be excluded due to the small sample size. Future larger studies may be required to determine the precise role of M. pneumoniae infection in the pathogenesis of different subtypes of ischaemic stroke, in all age groups, and in different ethnic populations.

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.

Neurological disorders associated with Mycoplasma pneumoniae infection

Neurological syndromes caused by Mycoplasma pneumoniae (MP) infection are occasionally reported in adults, usually in the post-infectious period, and three computed tomography documented cases have recently appeared in this journal. Here we present the cases of three young women with recent respiratory tract infection caused by MP some weeks prior to neurological complication documented by magnetic resonance imaging. Two cases suffered from demyelinating disorders of the central nervous system (CNS). The other case had a middle cerebral artery thrombosis, a rare complication of MP infection. Another potential risk factor for stroke in the latter case was the use of oral contraceptives. Recent infection with MP is discussed as a risk factor for cerebrovascular disorders and CNS demyelinating diseases.

Posterior cerebral artery occlusion associated with Mycoplasma pneumoniae infection

Cerebral infarction is a rare complication of Mycoplasma pneumoniae infection. In all cases previously reported in the literature, vascular occlusion occurred in the anterior brain circulation, either the internal carotid or the middle cerebral artery. We report a case of a child with posterior cerebral artery occlusion and resultant hemiparesis associated with M. pneumoniae infection.

Detection of Mycoplasma pneumoniae DNA in cerebrospinal fluid of a patient with M. pneumoniae infection-"associated" stroke

A 36-year-old woman presented with an acute ischemic stroke and a concomitant Mycoplasma pneumoniae infection that had been proven clinically, bacteriologically, and serologically. M. pneumoniae DNA was demonstrated in cerebrospinal fluid by positive nested polymerase chain reaction, and intrathecal antibody production was also detected. Contrary to previous reports about M. pneumoniae-associated stroke, most thrombostatic abnormalities in this patient occurred after stroke onset. Although the cause of stroke remains unclear in this patient, central nervous system invasion of M. pneumoniae DNA has to be considered a possible cause in rare cases of cerebral ischemia.

Middle cerebral artery occlusion after recent Mycoplasma pneumoniae infection

Stroke is a rare complication of Mycoplasma pneumoniae infection although recent studies suggest that infection may be a risk factor of acute ischemic stroke. We report a 5-year-old girl who had a stroke 10 days after M. pneumoniae infection. This is the first case of documented middle cerebral artery occlusion after Mycoplasma infection in children. In this article, we review other published reports on this topic and discuss the possible underlying mechanisms of the middle cerebral artery occlusion.