Mycoplasma pneumoniae-associated myelitis: a comprehensive review

Parainfectious Brown-Sequard syndrome associated with Mycoplasma pneumoniae in an adult patient: a case report

INTRODUCTION

Acute transverse myelitis (ATM) refers to a rare severe acquired spinal cord inflammation, with a challenging diagnostic work-up and treatment.

CASE PRESENTATION

We report the case of a 42-year-old patient who presented with loss of temperature and pain sensation beneath the C5 dermatome in her left side and reported a history of a possible respiratory tract illness 10 days ago. Within 2 days, clinical worsening was noted, compatible with Brown-Sequard syndrome. Spinal magnetic resonance imaging revealed a T2 sequence abnormal signal from level C4 to T3 and cerebrospinal fluid (CSF) studies showed only a mild pleocytosis mononuclear type. Extensive CSF and blood tests revealed only high Mycoplasma pneumoniae IgM and IgG titers. Treatment with high-dose intravenous methylprednisolone and oral azithromycin were administrated and the patient recovered completely within two months.

DISCUSSION

We would like to highlight the importance for physicians to consider M. pneumoniae in their differential diagnosis as a potential cause when encountering patients with symptoms of ATM and inflammatory Brown-Sequard syndrome.

Acute disseminated encephalomyelitis (ADEM) following COVID-19 vaccination: A systematic review

BACKGROUND

Although global vaccination against COVID-19 infection has its excellence, potential side effects are yet of concern. Several lines of evidence have proposed ADEM occurrence after SARS-CoV-2 infection. Moreover, a large number of case reports and case series have also suggested the casual association between ADEM and COVID-19 vaccination. To better understand the development of ADEM following COVID-19 vaccination and its potential association, we aimed to systematically review ADEM cases reported after COVID-19 vaccination.

METHODS

We conducted a comprehensive systematic search using three databases including PubMed, Scopus, and Web of Science. Studies that reported ADEM after COVID-19 vaccination were eligible to include in our study. Observational studies, case reports, and case series which reported cases of ADEM with sufficient detail to confirm clinical diagnosis following COVID-19 vaccination were eligible to enter our study.

RESULTS

Twenty studies were included in our systematic review after the abstract and full-text screening with a total of 54 cases. Among included patients, 45 (85.1 %) developed ADEM after the first dose of the COVID-19 vaccine, and seven (12.9 %) cases experienced ADEM after the second dose. The median time interval between vaccination and neurological symptoms was 14 days which ranged from 12 h to 63 days. Twelve (22.2 %) patients experienced symptoms of muscle weakness, ten (18.5 %) presented unconsciousness, nine (16.6 %) patients had urinary complaints, nine (16.6 %) had visual impairments, and five (9.2 %) experienced a seizure. After treatments, four (13.8 %) patients died. Forty-six patients had clinical improvement (85.1 %), also improvement in brain MRI was observed among 44 (81.4 %) patients.

CONCLUSION

In conclusion, it is not clear that ADEM could be a potential complication of COVID-19 vaccination based on the current evidence and further studies are needed. However, this rare condition should not trigger stopping the mass vaccination programs since the only way to eradicate the current pandemic of COVID-19 is to extend the number of immunized people.

Transverse Myelitis as a Rare Neurological Complication of Coronavirus Disease 2019: A Case Report and Literature Review

The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is primarily a respiratory virus. However, an increasing number of neurologic complications associated with this virus have been reported, e.g., transverse myelitis (TM). We report a case of a 39-year-old man admitted to Namazi Hospital affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. In December 2020, the patient was infected with Coronavirus Disease 2019 (COVID-19). During hospitalization, the patient suffered from sudden onset of paraplegia, and urinary retention, and had a T6-T7 sensory level. TM was diagnosed and an extensive workup was performed to rule out other etiologies. Eventually, para-infectious TM associated with COVID-19 was concluded. The patient received pulse methylprednisolone therapy of 1 g/day for 10 consecutive days followed by seven sessions of plasma exchange without a favorable response. The patient then underwent regular physical rehabilitation and tapering oral administration of prednisolone 1 mg/Kg. As a result, weakness in the lower extremities improved slightly after six months. Overall, we suspect a correlation between COVID-19 and TM, however, further studies are required to substantiate the association.

Post-COVID-19 longitudinally extensive transverse myelitis: is it a new entity?

Introduction

To the best of our knowledge, here we present two post-COVID19 longitudinally extensive transverse myelitis (LETM) with atypical presentations

Case presentations

A 44-year-old male who did not have any previous medical condition and a 73-year-old male foreigner who did not have any disease other than type 2 diabetes mellitus were admitted to our neurology clinic in the same period with similar clinical presentations of transverse myelitis. Upon admission, paraplegia and urinary-fecal incontinence were observed in their neurological examination. Neurological complaints had started within approximately 3–4 weeks following the resolution of the COVID-19 infection. Thoracic lower segment LETM was observed on spinal magnetic resonance imaging (MRI) in one of the patients, and long segment myelitis extending from the lower thoracic segment to the conus medullaris was observed in the other one. No significant diagnostic positivity was present in their diagnostic evaluation. In both cases, we assume a post-infectious etiology in terms of secondary immunogenic overreaction following COVID-19.

Conclusion

Our patients improved with multiple treatments such as methylprednisolone, intravenous immunoglobulin, and plasmapheresis. Whether post-infectious myelitis behaves differently from other viral infections after COVID-19 is currently unclear. Long lag times appear to be a post-infectious neurological complication resulting from the host response to the virus.

Acute Myelopathy in Childhood

Acute myelopathy presenting in childhood can be clinically classified based on the location of injury (with resulting spinal syndrome) or the cause (broadly traumatic or non-traumatic). Types of nontraumatic myelopathy include ischaemic, infectious, inflammatory, nutritional, and metabolic causes, some of which may be part of a systemic illness such as systemic lupus erythematosus or a demyelinating disease such as multiple sclerosis. Nonaccidental injury is an important consideration in cases of traumatic myelopathy, which may often be associated with other injuries. Assessment should include neuroimaging of the brain and spinal cord, with further investigations targeted based on the most likely differential diagnoses; for example, a child with suspected demyelinating disease may require specialist cerebrospinal fluid and serological testing. Management also will differ based on the cause of the myelopathy, with several of these treatments more efficacious with earlier initiation, necessitating prompt recognition, diagnosis, and treatment of children presenting with symptoms of a myelopathy. Important components of holistic care may include physiotherapy and occupational therapy, with multidisciplinary team involvement as required (for example psychological support or specialist bowel and bladder teams).

Acute disseminated encephalomyelitis (ADEM) following recent Oxford/AstraZeneca COVID-19 vaccination

This report describes the clinical context and autopsy findings in the first reported fatal case of acute disseminated encephalomyelitis (ADEM), developed after being vaccinated using the Oxford/AstraZeneca COVID-19 vaccine. ADEM is a rare autoimmune disease, causing demyelination in the brain and spinal cord. A wide variety of precipitating factors can trigger ADEM, and it has long been known to be a rare adverse event following some types of vaccinations. Recently, ADEM has also been associated with COVID-19 infection and (very rarely) with COVID-19 vaccination. The reports of the latter however all pertain to living patients. Our case demonstrates that ADEM should be considered in patients developing neurological symptoms post COVID-19 vaccination, although that this adverse reaction is likely to remain extremely rare. Our report further emphasizes the added value of comprehensive post mortem investigation to confirm ante mortem diagnosis and to determine vaccination safety.

Covid-19 post-infectious acute transverse myelitis responsive to corticosteroid therapy: report of two clinical cases

SARS-COV-2 infection has affected millions of individuals with a wide range of clinical manifestations, including central and peripheral nervous systems through several mechanisms. A rare but potentially severe manifestation of this virus is transverse myelitis. Herein, we report on two patients who developed paraparesis, sensory deficit, and autonomic changes on the tenth day after infection by COVID-19. A 27-year-old man, previously healthy, had symptoms of COVID-19 confirmed by oropharyngeal and nasopharyngeal swab tests. On the tenth day of symptoms, the patient started to experience acute paraparesis, urinary retention, constipation, and hypoesthesia up to the T4 level. The second patient is a 50-year-old man, previously healthy, who had symptoms of the flu-like syndrome. The diagnosis of COVID-19 infection was confirmed by oropharyngeal and nasopharyngeal swab tests. On the tenth day of symptoms, the patient started to experience paraparesis, urinary incontinence, and hypoesthesia up to the T6 level. The neuroimaging and cerebrospinal fluid (CSF) analysis of both patients confirmed acute transverse myelitis after COVID-19 infection. High-dose corticosteroid therapy was started, and both patients showed rapid recovery from their deficits. Although rare, post-infectious transverse myelitis may be related to SARS-COV-2 infection and should be quickly recognized. Although controlled studies are needed, treatment with corticosteroid therapy in high doses was effective in these patients.

Infectious Myelopathies

In the setting of both globalization and increasing use of immunosuppressive therapy, infectious myelopathies are an important cause of morbidity worldwide. Clinical spinal cord syndromes related to infection are varied, including transverse myelitis, acute flaccid paralysis related to anterior horn cell involvement, spinal cord compression, chronic spastic paraparesis, and myeloradiculitis. Causative pathogens include viruses, parasites, pyogenic and atypical bacteria, and fungi. The epidemiology, clinical characteristics, diagnosis, and treatment of selected organisms will be discussed in this article.

Acute infectious myelopathies

PURPOSE OF REVIEW

The patient who presents with an acute spinal cord syndrome with weakness/paralysis of the limbs presents a diagnostic. Two important syndromes are acute transverse myelitis (ATM) and acute flaccid paralysis (AFP). Both can be caused by a number of infectious and noninfectious causes. Since 2014 there have been outbreaks of acute flaccid myelitis (a subgroup of AFP) in the United States, with a national surveillance program underway. In addition, there have been increasing reports of ATM from new and emerging pathogens, and opportunistic infections in immunocompromised hosts.

RECENT FINDINGS

Infectious causes of ATM or AFP need to be ruled out first. There may be important clues to an infectious cause from epidemiologic risk factors, immune status, international travel, MRI, and laboratory findings. We summarize key features for the more common pathogens in this review. Advances in laboratory testing have improved the diagnostic yield from cerebrospinal fluid, including real-time polymerase chain reaction, metagenomic next-generation sequencing, and advanced antibody detection techniques. These tests still have limitations and require clinical correlation.

SUMMARY

We present a syndromic approach to infectious myelopathies, focusing on clinical patterns that help narrow the diagnostic possibilities.

Infectious Myelopathies

PURPOSE OF REVIEW

This article reviews infectious etiologies of spinal cord dysfunction, emphasizing the importance of recognizing common clinicoradiographic syndromes and interpreting them in the context of exposure risk and individual host susceptibilities.

RECENT FINDINGS

This article discusses the shifting spectrum of neurologic infectious diseases, the growing population of patients who are immunocompromised, and the emergence of effective antiretroviral therapies. In addition, it discusses new molecular and serologic tests that have the potential to enhance our ability to rapidly and accurately diagnose infectious diseases of the spine.

SUMMARY

When evaluating patients with suspected infectious myelopathies, it is imperative to narrow the range of pathogens under consideration. The geography, seasonality, and clinicoradiographic presentation and immunocompetence status of the patient define the range of potential pathogens and should guide testing and initial management.

Neurological and Neuropsychiatric Impacts of COVID-19 Pandemic

BACKGROUND

Albeit primarily a disease of respiratory tract, the 2019 coronavirus infectious disease (COVID-19) has been found to have causal association with a plethora of neurological, neuropsychiatric and psychological effects. This review aims to analyze them with a discussion of evolving therapeutic recommendations.

METHODS

PubMed and Google Scholar were searched from 1 January 2020 to 30 May 2020 with the following key terms: "COVID-19", "SARS-CoV-2", "pandemic", "neuro-COVID", "stroke-COVID", "epilepsy-COVID", "COVID-encephalopathy", "SARS-CoV-2-encephalitis", "SARS-CoV-2-rhabdomyolysis", "COVID-demyelinating disease", "neurological manifestations", "psychosocial manifestations", "treatment recommendations", "COVID-19 and therapeutic changes", "psychiatry", "marginalised", "telemedicine", "mental health", "quarantine", "infodemic" and "social media". A few newspaper reports related to COVID-19 and psychosocial impacts have also been added as per context.

RESULTS

Neurological and neuropsychiatric manifestations of COVID-19 are abundant. Clinical features of both central and peripheral nervous system involvement are evident. These have been categorically analyzed briefly with literature support. Most of the psychological effects are secondary to pandemic-associated regulatory, socioeconomic and psychosocial changes.

CONCLUSION

Neurological and neuropsychiatric manifestations of this disease are only beginning to unravel. This demands a wide index of suspicion for prompt diagnosis of SARS-CoV-2 to prevent further complications and mortality.

The neurology of COVID-19 revisited: A proposal from the Environmental Neurology Specialty Group of the World Federation of Neurology to implement international neurological registries

A comprehensive review of the neurological disorders reported during the current COVID-19 pandemic demonstrates that infection with SARS-CoV-2 affects the central nervous system (CNS), the peripheral nervous system (PNS) and the muscle. CNS manifestations include: headache and decreased responsiveness considered initial indicators of potential neurological involvement; anosmia, hyposmia, hypogeusia, and dysgeusia are frequent early symptoms of coronavirus infection. Respiratory failure, the lethal manifestation of COVID-19, responsible for 264,679 deaths worldwide, is probably neurogenic in origin and may result from the viral invasion of cranial nerve I, progressing into rhinencephalon and brainstem respiratory centers. Cerebrovascular disease, in particular large-vessel ischemic strokes, and less frequently cerebral venous thrombosis, intracerebral hemorrhage and subarachnoid hemorrhage, usually occur as part of a thrombotic state induced by viral attachment to ACE2 receptors in endothelium causing widespread endotheliitis, coagulopathy, arterial and venous thromboses. Acute hemorrhagic necrotizing encephalopathy is associated to the cytokine storm. A frontal hypoperfusion syndrome has been identified. There are isolated reports of seizures, encephalopathy, meningitis, encephalitis, and myelitis. The neurological diseases affecting the PNS and muscle in COVID-19 are less frequent and include Guillain-Barré syndrome; Miller Fisher syndrome; polyneuritis cranialis; and rare instances of viral myopathy with rhabdomyolysis. The main conclusion of this review is the pressing need to define the neurology of COVID-19, its frequency, manifestations, neuropathology and pathogenesis. On behalf of the World Federation of Neurology we invite national and regional neurological associations to create local databases to report cases with neurological manifestations observed during the on-going pandemic. International neuroepidemiological collaboration may help define the natural history of this worldwide problem.

Infectious Myelopathies

PURPOSE OF REVIEW

This article reviews bacterial, viral, fungal, and parasitic pathogens associated with myelopathy. Infectious myelopathies may be due to direct infection or parainfectious autoimmune-mediated mechanisms; this article focuses primarily on the former.

RECENT FINDINGS

Some microorganisms exhibit neurotropism for the spinal cord (eg, enteroviruses such as poliovirus and flaviviruses such as West Nile virus), while others are more protean in neurologic manifestations (eg, herpesviruses such as varicella-zoster virus), and others are only rarely reported to cause myelopathy (eg, certain fungal and parasitic infections). Individuals who are immunocompromised are at increased risk of disseminated infection to the central nervous system. Within the last few years, an enterovirus D68 outbreak has been associated with cases of acute flaccid paralysis in children, and emerging Zika virus infection has been concurrent with cases of acute flaccid paralysis due to Guillain-Barré syndrome, although cases of myelitis have also been reported. Associated pathogens differ by geographic distribution, with myelopathies related to Borrelia burgdorferi (Lyme disease) and West Nile virus more commonly seen in the United States and parasitic infections encountered more often in Latin America, Southeast Asia, and Africa. Characteristic CSF and MRI patterns have been identified with many of these infections.

SUMMARY

A myriad of pathogens are associated with infectious myelopathies. Host factors, geographic distribution, clinical features, CSF profiles, and MRI findings can assist in formulating the differential diagnosis and ultimately guide management.

Mycoplasma pneumoniaeassociated transverse myelitis presenting as asymmetric flaccid paralysis

Acute transverse myelitis is a rare spinal cord inflammatory disorder that manifests as sudden onset of motor, sensory, and autonomic dysfunctions. Here, we report a case of acute transverse myelitis in a 13- year-old boy secondary to Mycoplasma pneumoniae infection. He presented with left facial palsy and contralateral upper extremity weakness without sensory or autonomic changes. The patient was diagnosed with transverse myelitis based on his magnetic resonance imaging findings, although his presentation was mainly motor dysfunction, which is more consistent with acute flaccid paralysis.

Acute myelitis of children with positive anti-GM1 antibody: Case series and literature review

RATIONALE

To explore the clinical features, treatment, and prognosis of acute myelitis (AM) of children with positive blood anti- ganglioside (GM1) antibodies.

PATIENT CONCERNS

Two cases of AM of children with positive anti-GM1 antibody were retrospectively collected and followed up for 6 months. Two cases had positive helicobacter pylori IgG antibody, and Case 2 also had positive mycoplasma IgM antibody.

DIAGNOSES

Two cases had typical symptoms of myelitis, abnormal spinal magnetic resonance imaging (MRI), and positive serum anti-GM1 IgM.

INTERVENTIONS

They were treated with steroid, immunoglobulin and rehabilitation.

OUTCOMES

Symptoms of AM were relieved after treatment. After 6 months of follow-up, case 1 was fully recovered and case 2 was partially recovered. Summarizing previous reports in literature and our 2 cases, AM with positive anti-GM1 antibody can be induced by multiple pathogen infections. About 35.7% were fully recovered, 42.9% had mild sequelae, and 21.4% had severe sequelae.

LESSONS

Post-infection immune injury plays an important role in the pathogenesis of AM with positive anti-GM1 antibody. H pylori and Mycoplasma pneumoniae infection may also induce AM with positive anti-GM1 antibody. Screening and treatment of pathogens were required and only 21.4% patients had severe sequelae after treatment.

Community-Acquired Pneumonia Caused by Mycoplasma pneumoniae: How Physical and Radiological Examination Contribute to Successful Diagnosis

Mycoplasma pneumoniae is one of the most common causes of community-acquired pneumonia (CAP), particularly in young adults. Vital signs are usually normal except for temperature. On physical examination, general appearance is normal compared with that of typical pneumonia such as pneumococcal pneumonia patients. Mycoplasma sometimes causes ear infections such as otitis media. It is important to distinguish between typical pneumonia and atypical pneumonia such as mycoplasma pneumonia because having the right diagnosis allows for the use of the correct antibiotic to treat CAP while preventing development of drug-resistant bacteria and also decreasing medical cost. The symptoms and diagnosis of mycoplasma pneumonia is multi-fold. Auscultation of patients can demonstrate trace late inspiratory crackles or normal alveolar sounds; however, bilateral polyphonic wheezes can sometimes be heard because of bronchiolitis. With regard to radiological findings, a chest radiogragh often shows bilateral reticulonodular or patchy consolidation in both lower lobes. Pleural effusion is rarely observed in adult cases. Immunocompetent patients tend to reveal more extensive shadowing compared with immunocompromised patients. As serological diagnostic methods are not able to offer 100% reliable diagnosis, integration of physical and radiological examination is crucial to accurately diagnose mycoplasma pneumonia. Herein, I review the typical findings from physical examination and imaging patterns of patients with mycoplasma pneumonia.

Mycoplasma pneumoniae as a trigger for Henoch-Schönlein purpura in children

Mycoplasma pneumoniae is one of the most common causes of respiratory tract infections in children. Extrapulmonary manifestations are seen in up to 25% of infected patients. Extrapulmonary complications are associated with the central nervous system, gastrointestinal tract, skin changes, myocarditis, pericarditis, hemolytic anemia, thrombocytopenia and thrombosis. The majority of extrapulmonary symptoms are associated with skin changes such as exanthematous skin eruptions, erythema nodosum, urticaria, Stevens-Jonson syndrome. M. pneumoniae stimulates production of the interleukins and tumor necrosis factor (TNF) α and can cause vasculitis. Henoch-Schönlein purpura (HSP) is a leucoclastic vasculitis that affects small vessels. Clinical manifestations of HSP include typical rash, arthritis, gastrointestinal and sometimes renal involvement. The main feature in HSP is abnormal IgA deposits in vessel walls. Circulating abnormal glycosylated IgA 1 and IgG antibodies form immune complexes: IgA1-IgG and anti-IgA 1. Immune complexes activate cytokines, parts of complement and influence directly the endothelium. We report cases of three children with Henoch-Schönlein purpura with prolonged and recurrent skin and joint changes. The serological analysis (positive serum IgM) confirmed Mycoplasma pneumoniae infection. Treatment with clarithromycin caused complete regression of disease. We suggest that in the case of prolonged symptoms of vasculitis due to Henoch-Schönlein purpura, Mycoplasma pneumonia infection may be a potential cause of exacerbation of the disease.

Pathologic approach to spinal cord infections

The pathologic evaluation of spinal cord infections requires comprehensive clinical, radiological, and laboratory correlation, because the histologic findings in acute, chronic, or granulomatous infections rarely provide clues for the specific cause. This brief review focuses on the pathologic mechanisms as well as practical issues in the diagnosis and reporting of infections of the spinal cord. Examples are provided of the common infectious agents and methods for their diagnosis. By necessity, discussion is restricted to the infections of the medulla spinalis proper and its meninges, and not bone or soft tissue infections.

Novel aspects on the pathogenesis of Mycoplasma pneumoniae pneumonia and therapeutic implications

Mycoplasma pneumoniae (Mp) is a leading cause of community acquired pneumonia. Knowledge regarding Mp pneumonia obtained from animal models or human subjects has been discussed in many different reports. Accumulated expertise concerning this critical issue has been hard to apply clinically, and potential problems may remain undiscovered. Therefore, our multidisciplinary team extensively reviewed the literature regarding Mp pneumonia, and compared findings from animal models with those from human subjects. In human beings, the characteristic pathological features of Mp pneumonia have been reported as alveolar infiltration with neutrophils and lymphocytes and lymphocyte/plasma cell infiltrates in the peri-bronchovascular area. Herein, we demonstrated the novel aspects of Mp pneumonia that the severity of the Mp pneumonia seemed to depend on the host innate immunity to the Mp, which might be accelerated by antecedent Mp exposure (re-exposure or latent respiratory infection) through up-regulation of Toll-like receptor 2 expression on bronchial epithelial cells and alveolar macrophages. The macrolides therapy might be beneficial for the patients with macrolide-resistant Mp pneumonia via not bacteriological but immunomodulative effects. This exhaustive review focuses on pathogenesis and extends to some therapeutic implications such as clarithromycin, and discusses the various diverse aspects of Mp pneumonia. It is our hope that this might lead to new insights into this common respiratory disease.

A case of Mycoplasma pneumoniae-associated encephalomyelitis in a 16-year-old female presenting to an adult teaching hospital

We report a rare cause of encephalitis that is not often described in the adult clinical setting. Our case was a 16-year-old female who presented with a clinical picture of viral encephalitis; however, magnetic resonance imaging showed a demyelinating lesion of the left frontal lobe. In this age group, differential diagnoses of acute demyelination encephalomyelitis and multiple sclerosis were entertained. Further investigations demonstrated positive Mycoplasma pneumoniae serology. As a result, a diagnosis of Mycoplasma pneumoniae-associated encephalitis was made based on a process of exclusion.

Coexistence of myositis, transverse myelitis, and Guillain Barré syndrome following Mycoplasma pneumoniae infection in an adolescent

Guillain-Barré syndrome (GBS) and transverse myelitis may occur coexistently in the pediatric population. This may be explained by a shared epitope between peripheral and central nervous system myelin. Coexistent transverse myelitis, myositis, and acute motor neuropathy in childhood have not been previously described. We describe a 14-year-old female patient with transverse myelitis, myositis, and GBS following Mycoplasma pneumoniae infection. She presented with weakness and walking disability. Weakness progressed to involve all extremities and ultimately, she was unable to stand and sit. Based on the clinical findings, a presumptive diagnosis of myositis was made at an outside institution because of high serum creatine kinase level. The patient was referred to our institution for further investigation. Magnetic resonance imaging of spine revealed enhancing hyperintense lesions in the anterior cervicothoracic spinal cord. The electromyography revealed acute motor polyneuropathy. Serum M. pneumoniae IgM and IgG were positive indicating an acute infection. Repeated M. pneumoniae serology showed a significant increase in Mycoplasma IgG titer. The patient was given intravenous immunoglobulin for 2 days and clarithromycin for 2 weeks. She was able to walk without support after 2 weeks of hospitalization. This paper emphasizes the rarity of concomitant myositis, transverse myelitis, and GBS in children.

Chronic Lyme Disease and Co-infections: Differential Diagnosis

In Lyme disease concurrent infections frequently occur. The clinical and pathological impact of co-infections was first recognized in the 1990th, i.e. approximately ten years after the discovery of Lyme disease. Their pathological synergism can exacerbate Lyme disease or induce similar disease manifestations. Co-infecting agents can be transmitted together with Borrelia burgdorferi by tick bite resulting in multiple infections but a fraction of co-infections occur independently of tick bite. Clinically relevant co-infections are caused by Bartonella species, Yersinia enterocolitica, Chlamydophila pneumoniae, Chlamydia trachomatis, and Mycoplasma pneumoniae. In contrast to the USA, human granulocytic anaplasmosis (HGA) and babesiosis are not of major importance in Europe. Infections caused by these pathogens in patients not infected by Borrelia burgdorferi can result in clinical symptoms similar to those occurring in Lyme disease. This applies particularly to infections caused by Bartonella henselae, Yersinia enterocolitica, and Mycoplasma pneumoniae. Chlamydia trachomatis primarily causes polyarthritis. Chlamydophila pneumoniae not only causes arthritis but also affects the nervous system and the heart, which renders the differential diagnosis difficult. The diagnosis is even more complex when co-infections occur in association with Lyme disease. Treatment recommendations are based on individual expert opinions. In antibiotic therapy, the use of third generation cephalosporins should only be considered in cases of Lyme disease. The same applies to carbapenems, which however are used occasionally in infections caused by Yersinia enterocolitica. For the remaining infections predominantly tetracyclines and macrolides are used. Quinolones are for alternative treatment, particularly gemifloxacin. For Bartonella henselae, Chlamydia trachomatis, and Chlamydophila pneumoniae the combination with rifampicin is recommended. Erythromycin is the drug of choice for Campylobacter jejuni.

Clinical improvement precedes lesion size regression in a severe case of acute disseminated encephalomyelitis

Here, we present a case of a severe acute disseminated encephalomyelitis (ADEM) of a 42-year-old male patient. The diagnosis was established after brain biopsy and due to acutely evolving encephalopathy occurring in the context of atypical Mycoplasma pneumoniae (MP). We analysed the prominent MRI white matter lesions using a three-dimensional algorithm as cutting-edge technique to study morphological abnormalities and correlated them to the clinical condition of the patient. We found a discrepancy between the lesion size and the clinical deficits of the patient, actually the clinical improvement antedated the regression of the white matter lesions.

Neuroimaging in acute transverse myelitis

Transverse myelitis is an acute inflammatory condition. A relatively rare condition, the diversity of causes makes it an important diagnostic challenge. An approach to the classification and work-up standardizes diagnostic criteria and terminology to facilitate clinical research, and forms a useful tool in the clinical work-up for patients at presentation. Its pathogenesis can be grouped into four categories. Imaging appearances can be nonspecific; however, the morphology of cord involvement, enhancement pattern, and presence of coexistent abnormalities on MR imaging can provide clues as to the causes. Neuroimaging is important in identifying subgroups that may benefit from specific treatment.

Mycoplasmal cerebral vasculopathy in a lymphoma patient: presumptive evidence of Mycoplasma pneumoniae microvascular endothelial cell invasion in a brain biopsy

A 73-year-old man had episodic encephalopathy, ataxia and neuropathy. Symptoms largely resolved but adenopathy later lead to the diagnosis of a low-grade follicular lymphoma. The neurological symptoms soon recurred with new pontine calcifications identified by computed tomography. Brain biopsy revealed microvascular endothelial cell nuclear changes. Electron microscopy identified small polymorphic bacteria without a cell wall and with terminal and attachment organelles within endothelial cells and clustered in some microvascular lumina. Immunostaining was positive for Mycoplasma pneumoniae and convalescent serum enzyme immunoassay was positive for M. pneumoniae IgG. The patient again recovered and he was neurologically stable 33 months after the initial episode. The ultrastructural findings of the bacterial cells are distinctive of some mycoplasmal species when compared to other small bacteria. Mycoplasma-like organisms are reported in four autopsied patients who had chronic encephalopathy, movement disorders, and some of the same light- and electron-microscopic findings in the brain as our patient. Direct neuroinvasion by Mycoplasma species has been suggested, while anatomic observations in our patient and in the four autopsy cases show microvascular invasion but not parenchymal invasion. Most mycoplasmal encephalitis may be immune-mediated. The frequency of neurovascular invasion is not known. It may be rare and it may persist.

Causes of encephalitis and differences in their clinical presentations in England: a multicentre, population-based prospective study

BACKGROUND

Encephalitis has many causes, but for most patients the cause is unknown. We aimed to establish the cause and identify the clinical differences between causes in patients with encephalitis in England.

METHODS

Patients of all ages and with symptoms suggestive of encephalitis were actively recruited for 2 years (staged start between October, 2005, and November, 2006) from 24 hospitals by clinical staff. Systematic laboratory testing included PCR and antibody assays for all commonly recognised causes of infectious encephalitis, investigation for less commonly recognised causes in immunocompromised patients, and testing for travel-related causes if indicated. We also tested for non-infectious causes for acute encephalitis including autoimmunity. A multidisciplinary expert team reviewed clinical presentation and hospital tests and directed further investigations. Patients were followed up for 6 months after discharge from hospital.

FINDINGS

We identified 203 patients with encephalitis. Median age was 30 years (range 0-87). 86 patients (42%, 95% CI 35-49) had infectious causes, including 38 (19%, 14-25) herpes simplex virus, ten (5%, 2-9) varicella zoster virus, and ten (5%, 2-9) Mycobacterium tuberculosis; 75 (37%, 30-44) had unknown causes. 42 patients (21%, 15-27) had acute immune-mediated encephalitis. 24 patients (12%, 8-17) died, with higher case fatality for infections from M tuberculosis (three patients; 30%, 7-65) and varicella zoster virus (two patients; 20%, 2-56). The 16 patients with antibody-associated encephalitis had the worst outcome of all groups-nine (56%, 30-80) either died or had severe disabilities. Patients who died were more likely to be immunocompromised than were those who survived (OR = 3·44).

INTERPRETATION

Early diagnosis of encephalitis is crucial to ensure that the right treatment is given on time. Extensive testing substantially reduced the proportion with unknown cause, but the proportion of cases with unknown cause was higher than that for any specific identified cause.

FUNDING

The Policy Research Programme, Department of Health, UK.

The epidemiology of transverse myelitis

Transverse myelitis is a neurological disorder causing acute spinal cord injury as a result of acute inflammation, often associated with para infectious processes and autoimmune disease. The purpose of this article is to review the literature on the geoepidemiology of transverse myelitis and assess its environmental associations. Articles from 1981 to 2009 were reviewed in Pub Med along with potential causes such as autoimmune disease (focusing on systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome (APS), and Sjogren's), infection, vaccination, and intoxication.

Transverse myelitis as a rare, serious complication of Mycoplasma pneumoniae infection

We report on the first published case of a Mycoplasma pneumoniae-associated transverse myelitis appearing in childhood and leading to persistent paraplegia and bowel and bladder dysfunctions. Magnetic resonance imaging of the spinal cord indicated extensive transverse myelitis extending from T(5)-T(12). A repeated scan established spinal cord atrophy in the affected area. Various therapies (methylprednisolone pulse therapy, plasmapheresis, and roxythromycine) produced no clinical effect.

Pathogenesis of neurologic manifestations of Mycoplasma pneumoniae infection

Mycoplasma pneumoniae has been associated with various neurologic manifestations, but exactly how the organism can cause such a wide variety of diseases is a long-standing mystery. In this respect, although pneumonia has been considered the hallmark of Mycoplasma pneumoniae infection, emerging accumulations of data have revealed that the infection can cause a number of extrapulmonary manifestations even in the absence of pneumonia. The importance of host immune response in the pathomechanism of pneumonia has been established, but the pathomechanisms of extrapulmonary manifestations remain largely unknown. For this review, extrapulmonary manifestations due to M. pneumoniae infection were classified into three categories: a direct type, in which locally induced cytokines must play a role; an indirect type, in which immune modulation such as autoimmunity must play a role; and a vascular occlusion type, in which vasculitis or thrombosis (either or both, and with or without systemic hypercoagulable state) must play a role. This classification was then applied within a literature review for neurologic manifestations. Most neurologic manifestations due to M. pneumoniae infection could be reasonably classified into and explained by one of the three types of pathomechanisms.

Mycoplasma pneumoniae: nervous system complications in childhood and review of the literature

Mycoplasma pneumoniae is an important pathogen which causes nervous system disorders during or after the course of a respiratory tract infection. The exact pathogenic mechanism which causes neurological disorders still remains unknown. Although meningoencephalitis and acute disseminated encephalomyelitis are common complications, there are few cases of acute transverse myelitis and isolated abducens nerve palsy associated with M. pneumoniae infection in childhood. The association between ocular myasthenia gravis and M. pneumoniae infection has not been described before. Here, we describe five patients with different nervous system complications associated with M. pneumoniae infection and discuss the pathological features of central nervous system involvement.

A novel cerebral microangiopathy with endothelial cell atypia and multifocal white matter lesions: a direct mycoplasmal infection?

We present 3 sporadic cases of a subacute to chronic, progressive motor (i.e. weakness, ataxia, spasticity, dysarthria, and dysphagia) and cognitive disorder in adults of both sexes, without proven immunocompromise or malignancy. Neuroimaging studies revealed tiny calcifications with atrophy of the cerebrum, pons, and midbrain in 1 patient, cerebral atrophy in another, and cerebral atrophy and periventricular white matter hyperintensities in the third. Clinical diagnoses included cortico-pontine-cerebellar degeneration, mixed neurodegenerative disorder, progressive supranuclear palsy, diffuse Lewy body disease, and Lyme disease. One atrophic brain revealed widely disseminated, millimeter-sized gray lesions in cerebral white matter and obscured anatomic markings of the basis pontis. The most conspicuous microscopic feature in all was capillaries with focally piled up endothelial nuclei, some of which appeared to be multinucleated, or enlarged, hyperchromatic crescentic single nuclei. Although seen mostly without associated damage, they were also noted with white matter lesions displaying vacuolation, demyelination, spheroids, necrosis, vascular fibrosis, and mineralization; these were most severe in the basis pontis. Immunostains and probes to herpes simplex virus-I, -II, and -8; adenovirus, cytomegalovirus, varicella-zoster, Epstein-Barr virus, measles, JC virus, and herpes hominis virus-6 were negative. Electron microscopy revealed no virions in endothelial cells with multilobed or multiple nuclei and duplicated basal laminae. However, mycoplasma-like bodies, mostly 400 to 600 nm in size, were found in endothelial cell cytoplasm and capillary lumina. Platelets adhered to affected endothelial cells. Polymerase chain reaction and immunohistochemistry of fixed samples for Mycoplasma fermentans were negative; other species of Mycoplasma remain viable pathogenic candidates.

Mycoplasma pneumoniae-an emerging extra-pulmonary pathogen

Mycoplasma is a well-recognised pathogen that colonises mucosal surfaces of humans and animals. Mycoplasma pneumoniae infects the upper and lower respiratory tracts of children and adults, leading to a wide range of respiratory and non-respiratory clinical conditions. M. pneumoniae infection is frequently considered in the differential diagnosis of patients with respiratory illnesses, and is commonly managed empirically with macrolides and fluoroquinolones. This contrasts with patients who present with non-respiratory symptoms in the context of a recent or current unrecognised M. pneumoniae infection, for whom this pathogen is rarely considered in the initial differential diagnosis. This review considers the microbiological, epidemiological, pathogenic and clinical features of this frequent pathogen that need to be considered in the differential diagnosis of respiratory and non-respiratory infections.