Two distinct patterns of pleural effusions caused by Mycoplasma pneumoniae infection

Clinical profiles of Mycoplasma pneumoniae pneumonia in children with different pleural effusion patterns: a retrospective study

BACKGROUND

The clinical significance of the presence or absence of Mycoplasma pneumoniae (MP) in pleural effusion in Mycoplasma pneumoniae pneumonia (MPP) children has not yet been elucidated. Herein, we investigated the clinical implication of pleural fluid MP positive in children with MPP.

METHODS

A total of 165 MPP children with pleural effusion requiring thoracocentesis were enrolled in this study. They were subsequently divided into two groups according to the presence or absence of MP in pleural effusion, namely positive group (n = 38) and negative group (n = 127). Information on their clinical manifestations, laboratory findings, radiological characteristics and treatment modalities was retrospectively collected from medical chart reviews.

RESULTS

The length of hospitalization (15.00 (10.75-19.25) vs. 11.00 (9.00-14.00) days, p=0.001) and total course of illness (23.00 (18.00-28.00) vs. 20.00 (17.00-24.00) days, p=0.010) were significantly longer in the positive group than in the negative group. The occurrence of pericardial effusion (23.7% vs. 7.9%, p=0.017), atelectasis (73.7% vs. 53.5%, p=0.027) and necrotizing pneumonia (23.7% vs. 7.9%, p=0.017) were more frequent in the positive group compared to the negative group. The levels of neutrophil percentages (82.35% (75.40%-85.78%) vs. 72.70% (64.30%-79.90%), p<0.001), C-reactive protein (CRP) (71.12 (37.75-139.41) vs. 31.15 (13.54-65.00) mg/L, p<0.001), procalcitonin (PCT) (0.65 (0.30-3.05) vs. 0.33 (0.17-1.13) ng/ml, p=0.005), serum lactate dehydrogenase (LDH) (799.00 (589.00-1081.50) vs. 673.00 (503.00-869.00) U/L, p=0.009), D-dimer (6.21 (3.37-16.11) vs. 3.32 (2.12-6.62) mg/L, p=0.001) on admission were significantly higher in the positive group than in the negative group. These pronounced differences significantly contributed to the identification of MPP with MP positive pleural effusion, as evidenced by the ROC curve analysis. Marked elevations in adenosine deaminase (49.25 (36.20-60.18) vs. 36.20 (28.10-46.50) U/L, p<0.001) and LDH levels (2298.50 (1259.75-3287.00) vs. 1199.00 (707.00-1761.00) U/L, p<0.001) were observed in pleural fluid of the positive group when compared to the negative group. Meanwhile, the number of patients on low molecular weight heparin (LMWH) therapy (9 (23.7%) vs. 12 (9.4%), p=0.028) was higher in the positive group. Multivariate logistic regression analysis revealed that D-dimer > 7.33 mg/L was significantly associated with the incidence of MP positive pleural effusion in MPP (OR=3.517).

CONCLUSIONS

The presence of MP in pleural fluid in MPP children with pleural effusion indicated a more serious clinical course. D-dimer > 7.33 mg/L was a related factor for MP positive pleural effusion in MPP. The results of the present study would help in the creation of a therapeutic plan and prediction of the clinical course of MPP in children.

Mycoplasma pneumoniae Pleural Effusion in Adults

Parapneumonic effusions often complicate Mycoplasma pneumoniae (MP) pneumonia, contrary to the notion that they are a rare feature of MP infection. Increased research and evidence on MP parapneumonic effusions (MPPE) can help elucidate its clinical significance as one of the variable manifestations of MP infection. This article aims to summarize the existing literature about the clinical characteristics of MPPE in adults and discuss its diagnostic implications from the perspective of pleural fluid analysis. Approximately 20–25% of adult patients with MP pneumonia develop MPPE, and its frequency in children and adults seems to be similar. Although the pathogenesis of MPPE remains to be elucidated, MP-induced cell-mediated immune mechanisms might be partially associated with the development of MPPE. MPPE usually shows mononuclear leukocyte predominance with elevated adenosine deaminase (ADA) activity, similar to tuberculous pleural effusion (TPE). The degree of increase in pleural fluid ADA levels and serum inflammatory biomarkers may help differentiate between MPPE and TPE. During the acute phase, a single positive IgM and positive polymerase chain reaction results allow for a precise and reliable MP infection diagnosis. The mainstay of treatment is the selection of adequate anti-mycoplasma antibiotics with or without corticosteroid, based on the local epidemiologic data on macrolide resistance.

Clinical Significance of Pleural Effusion in Mycoplasma pneumoniae Pneumonia in Children

The clinical significance of pleural effusion in Mycoplasma pneumoniae (MP) pneumonia in children has not yet been elucidated. Herein, we investigated the clinical implications of pleural effusion in children with MP pneumonia. Overall, 150 children with MP pneumonia transferred to a tertiary hospital were enrolled in this study. Information on their clinical, laboratory, and radiological features was retrospectively obtained from medical chart reviews. In total, 24 (16.0%) children had pleural effusion at the time of admission. The duration of fever and length of hospitalization were significantly longer in the pleural effusion group than in the non-pleural effusion group. A significantly higher proportion of individuals in the pleural effusion group had a poor response to stepwise treatment for MP pneumonia. The mean C-reactive protein, lactate dehydrogenase, and aspartate aminotransferase levels were significantly higher in the pleural effusion group than in the non-pleural effusion group at admission. The prevalence of severe pneumonia, defined on the basis of the extent of pneumonic lesions on chest radiography, was higher in the pleural effusion group than in the non-pleural effusion group. However, there was no significant intergroup difference in the proportion of macrolide-resistant MP cases or respiratory viral coinfections. The presence of pleural effusion in children with MP pneumonia indicated a more severe clinical course and poor treatment response. The results of the present study would help in the creation of a therapeutic plan and prediction of the clinical course of MP pneumonia in children.

Mycoplasma pneumonia with hydropneumothorax: A case report

Mycoplasma pneumoniae is one of the most common causes of community-acquired pneumonia in adults. Mycoplasma pneumoniae pneumonia (MPP) presents with pulmonary and extrapulmonary manifestations. Pneumothorax is a rare MPP complication in children. But, we reported a case of MPP with hydropneumothorax in an adult. The association of MPP, hydropneumothorax, and empyema is extremely rare.

Mycoplasma pneumoniae Pneumonia with Worsening Pleural Effusion Despite Treatment with Appropriate Antimicrobials: Case report

Mycoplasma pneumoniae is a common cause of community-acquired pneumonia. As M. pneumoniae pneumonia is usually a mild and self-limiting disease, complications such as pleural effusion occur only rarely. We report a 22-year-old woman who presented to the Emergency Medicine Department of the Sultan Qaboos University Hospital, Muscat, Oman, in 2017 with an eight-day history of fever associated with coughing, chills and rigors. She was diagnosed with M. pneumoniae pneumonia, but subsequently developed pleural effusion which worsened despite treatment with appropriate antimicrobials. The pleural effusion required drainage, which revealed that it was of the more severe exudative type. Following drainage, the patient improved dramatically. She was discharged and advised to continue taking antibiotics.

Rare complicated parapneumonic effusion, Mycoplasma pneumoniae with new-onset lupus flare: Case report and literature review

Mycoplasma pneumoniae has been associated with respiratory tract infections. Mycoplasma pneumoniae pneumonia–related pleural effusion is rarely reported. Extra-pulmonary abnormalities such as encephalitis, myocarditis, glomerulonephritis, and myringitis have been reported. However pulmonary manifestations in systemic lupus erythematosus include pneumonitis, pleurisy, interstitial lung disease, and thromboembolic disease. We present the case of a 26-year-old male who came for evaluation of fever, cough, and shortness of breath with right-sided chest pain. He was found to have right-side loculated complicated parapneumonic effusion and underwent drainage with a pleural catheter followed by fibrinolytic therapy. He was then found to have new-onset systemic lupus erythematosus concomitant with Mycoplasma pneumonia, leading to lupus flare and lupus nephritis. He responded well to levofloxacin, steroids, hydroxychloroquine, and mycophenolate, with complete resolution of loculated pleural effusion and symptom improvement. Our case describes the rare combination of Mycoplasma pneumoniae pneumonia, parapneumonic pleural effusion, and lupus flare with lupus nephritis. Early identification and treatment can lead to better out come in young patients.

Massive empyema caused by Mycoplasma pneumoniae in an adult: a case report

Background

Mycoplasma pneumoniae is responsible for more than 20% of community acquired pneumonia cases, and capable of causing upper respiratory illness as well. Complications of M.pneumoniae infections include CNS involvement but other as pericarditis were also reported. The lack of feasible culture methods and under appreciation of the pathogens ability to cause invasive disease leads to reduced number of diagnosed M.pneumoniae related complications. In contrast to many other respiratory pathogens causing pneumonia, M. pneumoniae related severe pleural complications were almost never reported.

Case presentation

We report a previously healthy 57 years old woman presented with indolent massive right pleural effusion, leukocytosis and elevated ESR. Extensive microbiological evaluation didn't reveal any pathogen in the pus even before antibiotic treatment was started. Surprisingly, M.pneumoniae DNA was detected in the pus from the empyema using PCR designed to detect M.pneumoniae. A serological assay (Serodia-Myco II) using convalescent serum was indeterminate with a titer of 1:80. The patient responded well to a treatment that included right thoracotomy with pleural decortication and a combination of antibiotics and anti-inflammatory medications.

Conclusion

M.pneumoniae related empyema was never reported before in adult patients and was reported in only a few pediatric patients. In our patient there was no evidence to any common pathogens even before initiating antibiotic treatment. The only pathogen detected was M.pneumoniae. In this patient, serology was not helpful in establishing the diagnosis of M.pneumoniae related diseases, as was suggested before for older patients. We suggest that M.pneumoniae related empyema is probably under-diagnosed complication due to insensitivity of serology in older patients and under use of other diagnosis methods.