Posterior cerebral 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.

Mycoplasma pneumoniae pneumonia associated thrombosis at Beijing Children's hospital

Background

With the increase of awareness of mycoplasma pneumoniae pneumonia (MPP), we found thrombosis in severe MPP (SMPP) was not rare. The aim of the study was to investigate the clinical characteristics, treatment, and long-term prognosis of MPP-associated thrombosis.

Methods

We retrospectively reviewed the medical records of 43 children with MPP-associated thrombosis between January 2013 and June 2019 at Beijing Children’s Hospital. The results of blood coagulation studies, autoimmune antibody, thrombophilia screening, contrast-enhanced lung computed tomography, echocardiography, and blood vessel ultrasonography were analyzed, as were treatment outcomes.

Results

Forty-two patients were diagnosed with SMPP. D-dimer was higher than 5.0 mg/L in 58.1% (25/43) of patients. The mean D-dimer level was 11.1 ± 12.4 mg/L. Anticardiolipin-IgM was positive in 60.0% of patients, β2-glycoprotein-IgM in 64.0%, and lupus anticoagulant in 42.1%. Chest imaging revealed pulmonary consolidation with lobe distribution in all patients (2/3–1 lobe in 10 patients, > 1 lobe in 29 patients). In our experience, thrombosis can occur in a vessel of any part of the body, and it can be initially detected as late as 31 days after disease onset. Thrombosis in the brain and abdomen can occur early, at 5 days after disease onset. Pulmonary vessels were the most commonly involved sites in the current study, and accordingly chest pain was the most common symptom (32.6%), followed by neurological symptoms (14.0%) and abdominal pain (9.3%). Thirty-five percent of patients were asymptomatic with regard to thrombosis. All patients underwent anticoagulant therapy, and thrombus absorption took > 3 months in most patients. All patients were followed until October 2019, at which time 41 were asymptomatic and 2 had mild recurrent cough.

Conclusions

SMPP with pulmonary consolidation (> 2/3 lobe) was the most strongly associated risk factor for thrombosis. Thrombosis-associated symptoms may be subtle, even absent. Elevated D-dimer, specifically > 11.1 mg/L (even > 5.0 mg/L), would assist in the early diagnosis of thrombosis. The long-term prognosis of thrombosis was good after timely administration of anticoagulant therapy.

Thrombotic Complications of Nose and Toe Associated With Mycoplasma pneumoniae Infection

Thrombosis is a very rare complication of Mycoplasma pneumoniae (M. pneumoniae) infection. We report a case of a woman who has thrombotic complications associated with mycoplasma infection in distal body parts. A 79-year-old female patient applied to the emergency department with complaints of the pain and discoloration at the nose tip and distal toes of the feet. Those symptoms have occurred in 10 days after the onset of the respiratory problems. The venous obstruction was diagnosed by venous Doppler ultrasound related to the distal part of the toes. The occurrence of the thrombosis associated with M. pneumoniae could be explained with some reaction of the inflammatory products in the blood circulation.

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.

Mycoplasma pneumoniae infection presenting as stroke and meningoencephalitis with aortic and subclavian aneurysms without pulmonary involvement

A 39-year-old Philipino man presented with acute onset fever and headache. Neurological examination was normal except for neck stiffness. There was no history of chest pain, cough or breathlessness. Cerebrospinal fluid (CSF) showed a mild increase in protein with normal sugar and lymphocytic pleocytosis. CSF PCR for herpes simplex and varicella zoster virus was negative. He developed acute right haemiplegia a week after hospitalisation. MRI showed acute infarct in the left centrum semiovale. His angiogram showed aneurysm in the left subclavian artery and aortic arch. The mycoplasma antibody test came positive with very high titres, while rest of the workup was negative. He was treated with azithromycin and his symptoms improved completely.

He was asymptomatic on follow-up after a month. His repeat immunoglobulin G mycoplasma antibody titre showed elevation. Mycoplasma infection is a treatable cause of meningoencephalitis and stroke secondary to vasculitis. Arterial aneurysms are known to occur with mycoplasma infection although rare.

Evaluation of variation in coagulation among children with Mycoplasma pneumoniae pneumonia: a case-control study

Objective

Acute organ embolism in children with Mycoplasma pneumoniae pneumonia (MPP) has been reported, but changes in coagulation are unclear. This study aimed to investigate changes in coagulation in children with MPP.

Methods

A total of 185 children with MMP (cases) and 117 healthy children (controls) were recruited. We measured prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and plasma fibrinogen (FIB) and D-dimer levels.

Results

Plasma FIB (3.39 ± 0.96 g/L vs 2.93 ± 0.6 6g/L, t = 4.50) and D-dimer (326.45 ± 95.62mg/L vs 263.93 ± 103.32mg/L, t=5.36) in MPP children were higher than controls and PT (9.54 ± 4.97S vs 11.48 ± 5.96S, t=3.05) and APTT (31.41 ± 12.01S vs 38.38 ± 11.72S, t=4.95) were shorter than controls. FIB, D-dimer, PT, and APTT were not different between the high IgM-titre and low-titre groups. The areas under the receiver operating characteristic curves in cases and controls for plasma FIB and D-dimer levels were 0.654 (95% confidence interval [CI], 0.593–0.716, P = 0.031) and 0.682 (95% CI, 0.619–0.744, P = 0.032), respectively.

Conclusions

Children with MPP have a higher risk of blood coagulation and thrombosis. Controlling these problems should be considered as soon as possible.

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.

Cortical Blindness in a Child Secondary to Mycoplasma pneumoniae Infection

Our objective is to present a case of an uncommon complication associated with Mycoplasma pneumoniae infection in a child where cortical blindness was the main clinical feature. Stroke due to an infection by M. pneumoniae is very uncommon. No consensus has been reached on the pathogenesis, although several pathogenic mechanisms have been proposed. Occlusion of posterior cerebral circulation is the most uncommon central nervous system complication of M. pneumoniae infection being reported. Symptoms are usually hemiplegia and dysarthria. We report a case of a 6-year-old boy who suffered cortical blindness due to a stroke 2 days after M. pneumoniae infection. This is the first case of documented cortical blindness due to posterior cerebral arteries occlusion in children after M. pneumoniae infection.

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.

Childhood infections and trauma as risk factors for stroke

Stroke is as common as brain tumor in children. The etiology of childhood arterial ischemic stroke (AIS) appears to be multifactorial, resulting from the interaction between genetic predisposition and environmental triggers. The risk factors for AIS in children are markedly different from the atherosclerotic risk factors in adults. Trauma and infections have been identified as associations in previous studies and are exposures of particular interest because of their increased prevalence in the children. The aim of this review article is to provide an overview of the research studies that have addressed the role of infections and trauma in pediatric AIS.

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.

Persistently elevated IgA antibodies to Mycoplasma pneumoniae in patients with internal carotid artery stenosis

Background: It has been suggested that Mycoplasma pneumoniae may play a role in the development of atherosclerosis, but to date this association is still a matter of debate due to conflicting findings.

Methods: We have investigated the levels of specific IgA antibodies to M. pneumoniae in 91 patients with internal carotid artery (ICA) stenosis using a commercial kit (SeroMP™ IgA; Savyon Diagnostics, Israel; cut-off value: 20 binding units; BU). All patients underwent surgery for ICA stenosis. From each patient, the first serum sample (S1) was taken before surgery, and the second after an interval of 6 month (S2).

Results: The S1 seroprevalence was 18.7% (17/91). Thirteen of the 17 patients with positive S1 levels also remained positive after six month, whereby no decrease of IgA level was seen (median S1 level: 34 BU, range: 22–65 BU; median S2 level: 37 BU, range: 22–58 BU). Specifically, six of the patients showed an increased level after 6 months, and six a decrease, with the level remaining constant in one patient. In contrast, only 3 of the 74 S1 negative patients became positive for anti-M. pneumoniae IgA between the taking of the first and the second serum specimen (p<0.01). None of the assessed demographic factors or risk factors for atherosclerosis was associated with IgA seropositivity, neither were the degree CAVK or the degree of stenosis.

Conclusion: These findings cannot be explained throughout by the general seroprevalence, or by past respiratory tract infections with the pathogen, and therefore may suggest a role for M. pneumoniae in the development of atherosclerosis, since a chronic infection must be assumed.

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).

Cardiac thrombus associated with Mycoplasma pneumoniae infection

Thrombosis is a very rare complication of Mycoplasma pneumoniae infection. We report the case of a previously healthy nine-year-old boy with cardiac thrombus in the right ventricle associated with M. pneumoniae pneumonia. This cardiac thrombus was detected eight days after the onset of respiratory symptoms. The mechanism underlying thrombosis may be related to autoimmune modulations and was attributable to the production of transient antiphospholipid antibodies.

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.

Posterior cerebral artery occlusion after Mycoplasma pneumoniae infection associated with genetic defect of MTHFR C677T

Cerebral artery occlusion in childhood, particularly in the posterior circulation, is a rare neurological complication of Mycoplasma pneumoniae infection. A genetic defect in the methylenetetrahydrofolate reductase gene could result in hyperhomocysteinemia and increased risk of stroke. We report a patient with posterior cerebral artery occlusion after Mycoplasma pneumoniae infection associated with a homozygous, methylenetetrahydrofolate reductase gene mutant type.

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.

Stroke in two children with Mycoplasma pneumoniae infection. A causal or casual relationship?

We report on 2 children who had a stroke biologically related to Mycoplasma pneumoniae infection. Invasion of the central nervous system and an immune mechanism represent 2 pathogenesis pathways. Prompt macrolide therapy does not prevent stroke, but immediate and aggressive immunosuppressive treatment seems to help recovery.

Cytokines in Mycoplasma pneumoniae infections

Mycoplasma pneumoniae (M. pneumoniae) is one of the smallest free-living bacteria known. Along with other unique characteristics of this genus, it lacks the typical peptidoglycan cell wall of most eubacteria. Best known for causing tracheobronchitis and atypical pneumonia in humans, this pathogen also causes a number of extrapulmonary syndromes such as meningitis/encephalitis and arthritis. Recent studies also suggest that infection may be associated with chronic conditions such as asthma. Although the mechanisms of M. pneumoniae pathogenesis remain to be elucidated, one important component of M. pneumoniae infections is the induction of proinflammatory and other cytokines in both acute and chronic conditions. In this review, we survey the induction of cytokines by M. pneumoniae in different model systems, and we discuss the possible role of induced cytokines in M. pneumoniae pathogenesis.

Three cases of central nervous system complications associated with Mycoplasma pneumoniae

We report three new cases of acute central nervous system disease occurring shortly after Mycoplasma pneumoniae infection. The clinical phenotypes were characterized by encephalopathy (n = 2), optic neuritis (n = 1), transverse myelitis (n = 1), and seizures (n = 1). Although there was strong supportive evidence of preceding M. pneumoniae infection, cerebrospinal fluid polymerase chain reaction for M. pneumoniae was negative in all three patients. We propose that these cases resulted from a para-infectious immune-mediated process rather than parenchymal invasion by the microorganism. The two patients treated with steroids improved rapidly, and all three patients have made a full recovery. We review the literature regarding M. pneumoniae central nervous system complications and discuss the proposed pathologic mechanisms; para-infectious immune-mediated disease and parenchymal invasion of the central nervous system. Systematic investigation to discriminate between these two processes will be essential to select appropriate antibiotic and immunomodulatory therapies.