Mycoplasma pneumoniae-Associated Encephalitis: Favorable Aggressive Immunosuppression in a Patient

Abstract

Meningoencephalitis is the most important extrapulmonary manifestation of Mycoplasma pneumoniae infection. It is complicated by seizures in at least 40% of cases, and in half of them, status epilepticus can occur during the acute phase, often leading to severe neurological sequelae. Brain imaging ranges from normal to diffuse edema, focal changes, and abnormal signals in the white matter, basal ganglia, and hippocampi. Here, we describe a boy who presented with an acute onset of transient alteration of behavior, meningeal irritation, fever, vomiting, and leg pain. Meningoencephalitis due to M. pneumoniae infection was confirmed by focal pneumonia, positive immunological tests, and increased protein content in cerebrospinal fluid. Magnetic resonance imaging of the brain showed bilateral focal abnormalities in the temporoinsular cortex, and electroencephalographic recordings showed slow waves in the same regions. After early infusion of acyclovir on the first day, aggressive combination therapy with oral erythromycin, and intravenous methylprednisolone and immunoglobulin was promptly initiated once a complete diagnosis was obtained on the second day, and the boy recovered within a few days. Two weeks later, brain imaging findings had resolved completely. The rapid clinical and neuroradiological recovery after immunosuppressive therapy suggests an immune-mediated pathogenetic mechanism. He developed immune-mediated myositis 2 years later demonstrating the instability of his immunological status.

Keywords

encephalitis - immunosuppression - MRI - Mycoplasma pneumoniae

Authors' Contributions

Conceptualization was done by E.D.G., P.B., C.S., and C.F.; data curation by E.D.G., P.B., M.S., C.F., and L.R.B.; writing—original draft preparation by E.D.G.; and writing—review and editing by E.D.G., M.S., C.S., and T.S. All authors have read and agreed to the published version of the manuscript.

Publikationsverlauf

Eingereicht: 05. Mai 2023

Angenommen: 04. Dezember 2023

Artikel online veröffentlicht:
19. Februar 2024

• References

• 1 Daxboeck F, Blacky A, Seidl R, Krause R, Assadian O. Diagnosis, treatment, and prognosis of Mycoplasma pneumoniae childhood encephalitis: systematic review of 58 cases. J Child Neurol 2004; 19 (11) 865-871
• 2 Bitnun A, Ford-Jones E, Blaser S, Richardson S. Mycoplasma pneumoniae encephalitis. Semin Pediatr Infect Dis 2003; 14 (02) 96-107
• 3 Meyer Sauteur PM, Roodbol J, Hackenberg A. et al. Severe childhood Guillain-Barré syndrome associated with Mycoplasma pneumoniae infection: a case series. J Peripher Nerv Syst 2015; 20 (02) 72-78
• 4 Lerer RJ, Kalavsky SM. Central nervous system disease associated with Mycoplasma pneumoniae infection: report of five cases and review of the literature. Pediatrics 1973; 52 (05) 658-668
• 5 Steele JC, Gladstone RM, Thanasophon S, Fleming PC. Acute cerebellar ataxia and concomitant infection with Mycoplasma pneumoniae . J Pediatr 1972; 80 (03) 467-469
• 6 Gayatri N, Tyagi A, Mahadevan U. Acute hydrocephalus in a child with Mycoplasma cerebellitis. Brain Dev 2009; 31 (08) 618-621
• 7 Fusco C, Bonini E, Soncini G, Frattini D, Giovannini S, Della Giustina E. Transient basal ganglia and thalamic involvement following Mycoplasma pneumoniae infection associated with antiganglioside antibodies. J Child Neurol 2010; 25 (08) 1029-1033
• 8 El Hafidi N, Allouch B, Benbrahim F, Chellaoui M, El Mahraoui C. Encéphalite aiguë des noyaux gris centraux à Mycoplasma pneumoniae [Mycoplasma pneumoniae encephalitis associated with basal ganglia necrosis]. Rev Neurol (Paris) 2012; 168 (01) 49-52
• 9 Saker A, Athman S, Aldosari M, Frayha H. Encephalopathy and axonal neuropathy associated with Mycoplasma pneumoniae infection: response to intravenous immunoglobulin therapy. Child Neurol Open 2016; 3: X16632140
• 10 Roussel P, Poulat AL, Romaszko JP, Labbé A, Sarret C. Formes neurologiques des infections à Mycoplasma pneumoniae: à propos de neuf cas pédiatriques [Neurological symptoms due to Mycoplasma pneumoniae infection in nine children]. Arch Pediatr 2015; 22 (07) 699-707
• 11 Ramgopal A, Thavamani A, Ghori A. Association between posterior reversible encephalopathy syndrome and Mycoplasma pneumoniae infection. J Pediatr Neurosci 2018; 13 (01) 109-111
• 12 Lin JJ, Hsia SH, Wu CT, Wang HS, Lin KL. Mycoplasma pneumoniae-related postencephalitic epilepsy in children. Epilepsia 2011; 52 (11) 1979-1985
• 13 Ercan TE, Ercan G, Severge B, Arpaozu M, Karasu G. Mycoplasma pneumoniae infection and obsessive-compulsive disease: a case report. J Child Neurol 2008; 23 (03) 338-340
• 14 Wang IJ, Lee PI, Huang LM, Chen CJ, Chen CL, Lee WT. The correlation between neurological evaluations and neurological outcome in acute encephalitis: a hospital-based study. Eur J Paediatr Neurol 2007; 11 (02) 63-69
• 15 Lee WT, Yu TW, Chang WC, Shau WY. Risk factors for postencephalitic epilepsy in children: a hospital-based study in Taiwan. Eur J Paediatr Neurol 2007; 11 (05) 302-309
• 16 Lin JJ, Lin KL, Hsia SH, Wu CT, Chou IJ, Wang HS. Analysis of status epilepticus with Mycoplasma pneumoniae encephalitis. Pediatr Neurol 2010; 43 (01) 41-45
• 17 Arkilo D, Pierce B, Ritter F, Doescher JS, Frost M. Diverse seizure presentation of acute Mycoplasma pneumoniae encephalitis resolving with immunotherapy. J Child Neurol 2014; 29 (04) 564-566
• 18 Heatwole CR, Berg MJ, Henry JC, Hallman JL. Extreme spindles: a distinctive EEG pattern in Mycoplasma pneumoniae encephalitis. Neurology 2005; 64 (06) 1096-1097
• 19 Sheth RD, Goulden KJ. Mycoplasma pneumoniae-associated encephalitis: extension of the clinical spectrum. [abstract] Ann Neurol 1992; 32: 448-449
• 20 Caceres ME, de los Reyes EC, Khan R, Caceres MJ. Acute encephalopathy and intractable seizures in a 10-year-old boy. Semin Pediatr Neurol 1999; 6 (03) 229-231 , discussion 231–232
• 21 Chambert-Loir C, Ouachee M, Collins K, Evrard P, Servais L. Immediate relief of Mycoplasma pneumoniae encephalitis symptoms after intravenous immunoglobulin. Pediatr Neurol 2009; 41 (05) 375-377
• 22 Shan L-S, Liu X, Kang X-Y, Wang F, Han X-H, Shang Y-X. Effects of methylprednisolone or immunoglobulin when added to standard treatment with intravenous azithromycin for refractory Mycoplasma pneumoniae pneumonia in children. World J Pediatr 2017; 13 (04) 321-327
• 23 Narita M. Pathogenesis of neurologic manifestations of Mycoplasma pneumoniae infection. Pediatr Neurol 2009; 41 (03) 159-166
• 24 Powers JM, Johnson MD. Mycoplasmal panencephalitis: a neuropathologic documentation. Acta Neuropathol 2012; 124 (01) 143-148
• 25 Meyer Sauteur PM, Jacobs BC, Spuesens EB. et al. Antibody responses to Mycoplasma pneumoniae: role in pathogenesis and diagnosis of encephalitis?. PLoS Pathog 2014; 10 (06) e1003983