Pediatric Pulmonology 34:122–127 (2002)

Cytokine Secretion in Children With Acute Mycoplasma

pneumoniae Infection and Wheeze
Susanna Esposito, MD, Roberta Droghetti, MD, Samantha Bosis, MD, Laura Claut, MD,
Paola Marchisio, MD, and Nicola Principi, MD*
Summary. The aim of this study was to evaluate cytokine secretion in children with acute
Mycoplasma pneumoniae infection and wheeze. We studied 25 patients aged 2–14 years with an
acute episode of wheezing (15 with acute M. pneumoniae infection) and 16 healthy controls of
similar gender and age (8 with laboratory evidence of asymptomatic acute M. pneumoniae
infection). Serum interleukin (IL)-2, interferon (IFN)-g, IL-4, and IL-5 concentrations were mea-
sured in samples obtained at enrollment, using enzyme-linked immunosorbent assay kits.
In the presence of wheezing, IL-5 concentrations were significantly higher in subjects with
acute M. pneumoniae infection (33.415
22.138 pg/mL) than in those without such infection
(2.320
1.846 pg/mL, P < 0.0001). The children with acute M. pneumoniae infection and wheeze
had higher IL-5 concentrations (33.415
22.138 pg/mL) than those with asymptomatic acute
infection and without wheeze (1.740
2.299 pg/mL, P < 0.0001). No significant between-group
differences were observed in terms of IL-2, IFN-g, or IL-4 levels, or the prevalence of atopy.
Our results show that children with wheezing and acute M. pneumoniae infection have a
specific cytokine profile characterized by a significant increase in serum levels of IL-5. This
immune response may be important for understanding the pathophysiological mechanisms
by which this pathogen contributes to the development of wheeze-related symptoms, and for
identifying new treatment strategies. Pediatr Pulmonol. 2002; 34:122–127. ß 2002 Wiley-Liss, Inc.

Key words: cytokines; Mycoplasma pneumoniae; wheezing; children; asthma.

INTRODUCTION explain the association between it and the subsequent

development of asthma.16–18 However, recent studies of
Mycoplasma pneumoniae is a frequent respiratory
RSV have shown that only IL-5 seems to be essential for
pathogen that is responsible for a large proportion of
the development of airway hyperresponsiveness.19,20
cases of lower respiratory tract infections, and has been
To the best of our knowledge, only a few published
associated with acute wheezing and asthma.1–5 In some
reports concern the role of cellular immunity in respi-
studies, acute M. pneumoniae infection has been diag-
ratory diseases due to M. pneumoniae,21–24 and none of
nosed in up to 20–25% of children experiencing acute
them involved children with wheezing. The aim of this
asthma exacerbations.2,3,6 Increased bronchoconstriction
study was to evaluate cytokine secretion in children with
with acute infection and impaired pulmonary function,
acute M. pneumoniae infection and wheezing.
especially of the small airways, has also been described
for up to 3 years after the initial infection.7–9 Moreover,
recent investigations suggest that timely and effective
treatment of acute M. pneumoniae respiratory infection
can improve the course of reactive airway disease beyond Pediatric Department I, University of Milan, Milan, Italy.
the acute episode of wheeze.2–4 Although the clinical
significance of M. pneumoniae infection is becoming Presented in part at the 22nd International Congress of Chemotherapy,
evident, the pathophysiological mechanisms by which Amsterdam, The Netherlands, July 2001.
the pathogen contributes to the development of wheeze-
Grant sponsor: Abbott Spa, Italy.
related symptoms, and to the onset or exacerbation of
asthma, are not yet fully understood. *Correspondence to: Nicola Principi, M.D., Pediatric Department I,
It was recently shown that the release of type 2 cyto- University of Milan, Via Commenda 9, 20122 Milan, Italy.
kines, including interleukin (IL)-4 and IL-5, is increased E-mail: Nicola.Principi@unimi.it
in asthmatic subjects, whereas the level of type 1 cytokine
Received 31 October 2001; Accepted 16 April 2002.
interferon (IFN)-g production is normal or low.10–15 A
type 2 cytokine profile has also been mentioned in respi- DOI 10.1002/ppul.10139
ratory syncytial virus (RSV) infection and may therefore Published online in Wiley InterScience (www.interscience.wiley.com).
ß 2002 Wiley-Liss, Inc.

MATERIALS AND METHODS
Study Subjects
Fifteen patients with, and 10 without laboratory evi-
dence of acute M. pneumoniae infection, were enrolled
from the children aged 2–14 years attending our
Pediatric Emergency Department because of an acute
episode of wheezing (defined as cough and/or dyspnea,
always with expiratory rales and wheezes) associated
with fever and signs or symptoms of upper respiratory
tract infection. In order to have an adequate control
group, 110 healthy subjects of similar gender and age,
with no history of respiratory tract infection in the
3 months preceding enrollment, seen at our Pediatric
Department for minor surgical problems, were evaluated:
among them, 8 (7.3%) had laboratory evidence of asymp-
tomatic acute M. pneumoniae infection. These 8 children
and the first 8 without laboratory evidence of asympto-
matic acute M. pneumoniae infection entered the study.
Appropriate written informed consent was obtained
from the parents or legal guardians of all participants, and
the research was conducted in accordance with the guide-
lines for human experimentation specified by the authors’
institution.
Methods
Serum samples for the determination of antibodies to
M. pneumoniae, C. pneumoniae, and RSV, and nasophar-
yngeal aspirates for M. pneumoniae and C. pneumoniae
DNA detection, were obtained from all subjects upon
enrollment and after 4–6 weeks. The serological studies
were performed using an enzyme-linked immunosorbent
assay (ELISA; Pantec, Turin, Italy) for immunoglobulin
(Ig)M and IgG directed against M. pneumoniae and
RSV, and a microimmunofluorescence test (Labsystems,
Helsinki, Finland) for IgM, IgG, and IgA directed against
C. pneumoniae.
Nested polymerase chain reaction (PCR) was perfor-
med to detect M. pneumoniae and C. pneumoniae DNA,
using validated methods as previously described.25,26
In order to avoid the risk of contamination, sample
preparation, PCR amplification, and product analysis
ABBREVIATIONS
ELISA Enzyme-linked immunosorbent assay
IgA Immunoglobulin A
IgG Immunoglobulin G
IgM Immunoglobulin M
IFN-g Interferon-g
IL-2 Interleukin-2
IL-4 Interleukin-4
IL-5 Interleukin-5
PCR Polymerase chain reaction
RSV Respiratory syncytial virus
SD Standard deviation
Cytokines in Mycoplasma pneumoniae Infection 123
were performed in separate rooms. Positive and negative
controls were included in each assay. The MP-1 and
MP-2 primer set was used for M. pneumoniae-specific
amplification.25 The reaction volumes for the first and
second rounds of amplification were 50 mL, with 0.1 mM
of each primer. Amplification was carried out for
40 cycles. The MUH-1 and MUH-2 primers were used
for M. pneumoniae nested PCR. The nested amplification
was performed using 5 mL of 1:10-diluted PCR product
(5 mL in 45 mL of sterile water) from the first round of
amplification under identical conditions. Touchdown
nested PCR for the detection of C. pneumoniae DNA
was performed using primers designed to detect the
major outer-membrane protein.27 Extracted DNA solu-
tion (10 mL in a total volume of 50 mL) was used in the
first PCR round, and then 5 mL of the PCR products
amplified by the outer primers were transferred to a new
50-mL PCR reaction mix for a second amplification
using the inner primers.26 The first round consisted of
40 cycles, and the second of 35. Acute M. pneumoniae
and/or C. pneumoniae infection was diagnosed if the
patient had a significant antibody response to the patho-
gens in the paired sera (M. pneumoniae: specific IgM
1:100, specific IgG 1:400, or a fourfold increase in
IgG titer; C. pneumoniae: specific IgM 1:16, specific
IgG 1:512, or a fourfold increase in IgG titer) and/or
if the nasopharyngeal aspirates were PCR-positive.1,2
Acute RSV infection was diagnosed in the presence of a
specific and significant antibody response in the paired
sera (specific IgM 1:100, specific IgG 1:400, or a
fourfold increase in IgG titer).28
For comparative purposes, in order to investigate if the
study group and the control group were similar in respect
to atopy, both the wheezing and the control children
underwent skin prick tests for common allergens on the
arm, as previously described.2,29 The standard battery
of extracts was Soluprick1 SQ 10 HEP (ALK A/S,
Hörsholm, Denmark), consisting of hen’s egg white,
cow’s milk, house-dust mite (Dermatophagoides ptero-
nyssinus and Dermatophagoides farinae), dog and cat
dander, birch and timothy pollen, mugwort (Artemisia
vulgaris), Aspergillus mix, and Alternaria tenuous. The
size of the reactions was measured 15 min after testing.
The histamine wheal size was recorded as the sum of the
longest plus the midpoint orthogonal diameters divided
by 2. A child was considered atopic to a specific allergen
if the average diameter of the wheal was at least half of
that produced by a 10-mg/mL solution of histamine,
provided that the diameter of the histamine-induced
wheal was at least 3 mm.2,29 Atopy was defined as at least
one positive skin prick test.
The study was approved by the Institutional Review
Board of the University of Milan, and written informed
consent was obtained from the parents or legal guardians
of all participants.
124 Esposito et al.

TABLE 1— Characteristics of Study Subjects1 children and healthy controls in terms of gender, age,
prevalence of M. pneumoniae infection, atopy or eczema,
Children with
Characteristics wheeze (n ¼ 25) Controls (n ¼ 16)
or family history of atopic diseases and asthma. None of
the patients and none of the healthy controls had any
Males 12.0 (48.0%) 7.0 (43.7%) laboratory signs of acute C. pneumoniae or RSV infection.
Median age (range), years 5.6 (2–14) 6.0 (2–14) Table 2 lists results of serology and PCR for the diag-
Acute M. pneumoniae infection 15.0 (60.0%) 8.0 (50.0%)
Acute C. pneumoniae infection 0.0 0.0 nosis of acute M. pneumoniae infection: it was serolo-
Acute RSV infection 0.0 0.0 gically determined in all 15 infected children with
Atopy 9.0 (36.0%) 5.0 (31.2%) wheeze and in the 8 infected healthy controls; in 10 of
Eczema 3.0 (12.0%) 1.0 (6.2%) the wheezing children (66.7%) and 4 (50.0%) of the
Family history of atopic 4.0 (16.0%) 2.0 (12.5%) healthy controls, M. pneumoniae DNA was also detected.
diseases
Family history of asthma 3.0 (12.0%) 2.0 (12.5%) In none of the study subjects was M. pneumoniae
DNA identified in the absence of a significant serologic
1
No significant differences were observed. RSV, respiratory syncytial response. The distribution of serologic and PCR-positive
virus. results was similar in children with wheezing and healthy
controls.
Cytokine Secretion Figure 1 describes cytokine secretion in the wheezing
children and healthy controls. The mean
SD for IL-4
The levels of IL-2, IFN-g, IL-4, and IL-5 were evalu-
and IL-5 levels in the wheezing children were, respec-
ated in the sera obtained at the time of enrollment, using
tively, 2.090
1.301 pg/mL and 20.977
22.977 pg/mL,
commercial ELISA kits (Endogen, Inc., Woburn, MA),
significantly higher than in the healthy controls (IL-4:
according to the manufacturer’s instructions. ELISA
0.986
1.602 pg/mL, P ¼ 0.028; IL-5: 1.285
1.684 pg/
sensitivity was <2 pg/mL for IFN-g, <6 pg/mL for IL-2,
mL, P < 0.0001). The means
standard deviations for
<2 pg/mL for IL-4, and <2 pg/mL for IL-5.
IL-2 and IFN-g levels were not significantly higher in the
wheezing children compared to healthy controls (2.539

Statistical Analysis
5.688 pg/mL and 1.839
3.042 pg/mL vs. 0.648

Cytokine levels were expressed per milliliter in serum, 0.918 pg/mL and 1.288
1.735 pg/mL, respectively).
and are presented as mean values
standard deviation Figure 2 summarizes cytokine secretion in the study
(SD). The data were recorded in a computerized database population according to the presence or absence of acute
and descriptively analyzed using the SPSS statistical M. pneumoniae infection and clinical symptoms. In the
package (SPSS, Chicago, IL). The differences between presence of wheeze, IL-5 concentrations were signif-
proportions were assessed by means of w2 test with Yates’ icantly higher in the subjects with acute M. pneumoniae
correction or Fisher’s exact test; the differences between infection (33.415
22.138 pg/mL) than in those without
mean values were assessed using the Mann-Whitney U (2.320
1.846 pg/mL, P < 0.0001). No significant dif-
test. Each difference with P < 0.05 (two-tailed) was con- ferences were observed in IL-2, IFN-g, and IL-4 con-
sidered significant. centrations, or in the prevalence of atopy between
subjects with or without evidence of acute M. pneumo-
niae infection. Comparison of healthy controls with
RESULTS
and without acute M. pneumoniae infection showed no
Table 1 shows the characteristics of the study subjects. significant differences in serum cytokine levels or the
There were no significant differences between wheezing prevalence of atopy. Among the children with acute

TABLE 2— Diagnosis of Acute M. pneumoniae Infection on Basis of Serologic and PCR

Techniques1

Infected children with Infected controls

Diagnostic technique wheeze (n ¼ 15) (n ¼ 8)

Serology-positive only (%) 5 (33.3) 4 (50.0)

lgM 1:100 and a fourfold increase in lgG titer (%) 3 (20.0) 3 (37.5)
lgM 1:100 and lgG 1:400 (%) 2 (13.3) 1 (12.5)
Serology and PCR-positive (%) 10 (66.7) 4 (50.0)
lgM 1:100, a fourfold increase in lgG titer, and 9 (60.0) 3 (37.5)
PCR-positive (%)
lgM 1:100, lgG 1:400, and PCR-positive (%) 1 (6.7) 1 (12.5)
PCR-positive only (%) 0 (0.0) 0 (0.0)
1
No significant differences were observed. PCR, polymerase chain reaction; lg, immunoglobulin.
 Cytokines in Mycoplasma pneumoniae Infection 125

Fig. 1. Cytokine secretion in children with wheeze and healthy controls. Mean values and
standard deviations are shown.

M. pneumoniae infection, IL-5 concentrations were signi-
ficantly higher in the presence of wheeze (33.415

22.138 pg/mL vs. 1.740
2.299, P < 0.0001); no other
significant differences were observed. Among the
children without acute M. pneumoniae infection, serum
cytokine levels and the prevalence of atopy were similar,
regardless of the presence of respiratory symptoms.
There was no relationship between the type or amount of
cytokine secretion and the level of M. pneumoniae
antibody response and/or PCR detection.
DISCUSSION
Although the available evidence has supported an asso-
ciation between M. pneumoniae infection and wheeze-
related symptoms,1–5 the mechanism by which the infec-
tion leads to this clinical picture is still unknown. This is
the first report concerning the cytokine profile in children
with wheeze associated with acute M. pneumoniae
infection. Despite the small sample size, our data suggest
that these children have a specific cytokine profile that is
characterized by a significant increase in serum IL-5,
whereas IL-4, IL-2, and IFN-g remain unchanged or are
only slightly and not significantly increased.
The cytokine profile of children with acute M. pne-
umoniae infection and wheeze seems to be different from
that of those without wheeze. The data reported in the
recent literature indicate that there is an increase in IL-4
and IL-2, with a predominant type 2-like cytokine
response in the bronchoalveolar lavage fluid of children
with M. pneumoniae pneumonia.22 However, in vitro
studies have shown that these findings are not con-
stant.23,30–32 The results of studies of IFN-g are also
controversial: Aray et al. found increased levels,33 but
other authors described the suppression of IFN-g pro-
duction during the acute stage of M. pneumoniae
infection.21,24 To the best of our knowledge, no data are
available concerning IL-5 responses in M. pneumoniae
infection.
As the appearance of wheeze in association with acute
M. pneumoniae infection involves only a minority of in-
fected children, it is possible that M. pneumoniae triggers
the ‘‘wheezing process’’ by means of IL-5 secretion in
subjects who are predisposed as a result of their genetic
background or previous events that have primed their
immune system and lungs. On the other hand, it has been
observed that the release of IL-5 in RSV bronchiolitis
may not only modulate host capacity to mount effective

Fig. 2. Cytokine secretion in study population by presence of acute Mycoplasma pneumoniae

infection and clinical symptoms. Mean values and standard deviations are shown.
126 Esposito et al.
responses against the pathogen, but may also partici-
pate in the immunopathology of the infection and in the
association between RSV and acute asthma.10,16–20 In
this context, Martinez suggested that IL-5 and other type
2 cytokines could stimulate the release of inflammatory
mediators from epithelial cells and macrophages, which
could then act alone or in synergy with common micro-
organisms.10 Moreover, after monitoring airway respon-
siveness, pulmonary inflammation, and local cytokine
production in a murine model of RSV infection,
Schwarze et al. found that the lack of IL-5 is the critical
element preventing eosinophilic airway inflammation
and the development of hyperresponsiveness.19,20 IL-5
can therefore cause a high level of local inflammation that
has little protective value, but may cause considerable
local damage to host tissues.
The relationship between IL-5 secretion and infection
due to M. pneumoniae is also supported by the fact that
we did not find any significant difference in the pre-
valence of atopy between the wheezing children with and
without acute M. pneumoniae infection. Consequently,
atopy does not explain the differences in the cytokine
profile.
In conclusion, our findings show that increased serum
IL-5 levels are markers of wheeze-related symptoms
in children with acute M. pneumoniae infection. How-
ever, the study was confined to the acute phase of
wheeze and cannot answer questions concerning the
possible duration of the imbalance in cytokine secretion
after M. pneumoniae infection. A prospective study is
needed to determine the duration of the IL-5 response,
including an evaluation of the relationship between
recurrences and bronchial hyperresponsiveness to lung
function tests. A better understanding of the specific
immune responses to M. pneumoniae in subjects with
wheeze may be important for identifying new treatment
strategies.
REFERENCES
1. Principi N, Esposito S, Blasi F, Allegra L, Mowgli Study Group.
Role of Mycoplasma pneumoniae and Chlamydia pneumoniae in
children with community-acquired lower respiratory tract infec-
tions. Clin Infect Dis 2001;32:1281–1289.
2. Esposito S, Blasi F, Arosio C, Fioravanti L, Fagetti L, Droghetti R,
Tarsia P, Allegra L, Principi N. Importance of acute Mycoplasma
pneumoniae and Chlamydia pneumoniae infection in children
with wheezing. Eur Respir J 2000;16:1142–1146.
3. Esposito S, Principi N. Asthma in children: are Chlamydia or
Mycoplasma involved? Paediatr Drugs 2001;3:159–168.
4. Emre U, Roblin PM, Gelling M, Dumornay W, Rao M,
Hammerschlag M, Schachter J. The association of Chlamydia
pneumoniae infection and reactive airway disease in children.
Arch Pediatr Adolesc Med 1994;148:727–732.
5. Cunningham AF, Johnston SL, Julious SA, Lampe FC, Ward ME.
Chronic Chlamydia pneumoniae infection and asthma exacerba-
tions in children. Eur Respir J 1998;11:345–349.
6. Gil JC, Cedillo RL, Mayagoitia BG, Paz MD. Isolation of
Mycoplasma pneumoniae from asthmatic patients. Ann Allergy
1993;70:23–25.
7. Mok JY, Waugh PR, Simpson H. Mycoplasma pneumoniae
infection. A follow-up study of 50 children with respiratory
illness. Arch Dis Child 1979;54:506–511.
8. Sabato AR, Martin AJ, Marmion BP, Kok TW, Cooper DM.
Mycoplasma pneumoniae: acute illness, antibiotics, and subse-
quent pulmonary function. Arch Dis Child 1984;59:1034–1037.
9. Todisco T, de Benedictis FM, Dottorini M. Viral and Mycoplasma
pneumoniae pneumonias in school-age children: three-year follow-
up of respiratory function. Pediatr Pulmonol 1989;6: 232–236.
10. Martinez FD. Viral infections and the development of asthma. Am
J Respir Crit Care Med 1995;151:1644–1648.
11. Ying S, Durham SR, Corrigan CJ, Hamid Q, Kay AB. Phenotype
of cells expressing mRNA for Th2-type (interleukin 4 and inter-
leukin 5) and Th1-type (interleukin 2 and interferon gamma)
cytokines in bronchoalveolar lavage and bronchial biopsies from
atopic asthmatic and normal control subjects. Am J Respir Cell
Mol Biol 1995;12:477–487.
12. Mazzarella G, Bianco A, Catena E, De Palma R, Abbate GF. Th1/
Th2 lymphocyte polarization in asthma. Allergy [Suppl] 2000;55:
6–9.
13. Hamid QA, Cameron LA. Recruitment of T cells to the lung in
response to antigen challenge. J Allergy Clin Immunol [Suppl]
2000;106:227–234.
14. Hamelmann E, Gelfand EW. IL-5-induced airway eosinophilia—
the key to asthma? Immunol Rev 2001;179:182–191.
15. Message SD, Johnston SL. The immunology of virus infection in
asthma. Eur Respir J 2001;18:1013–1025.
16. Hussell T, Spender LC, Georgiou A, O’Garra A, Openshaw PJ.
Th1 and Th2 cytokine induction in pulmonary T cells during
infection with respiratory syncytial virus. J Gen Virol 1996;77:
2447–2455.
17. Roman M, Calhoun WJ, Himton KL, Avendano LF, Simon V,
Escobar AM, Gaggero A, Diaz PV. Respiratory syncytial virus
infection in infants is associated with predominant Th2-like
response. Am J Respir Crit Care Med 1997;156:190–195.
18. van Schaik SM, Welliver RC, Kimpen JLL. Novel pathways in the
pathogenesis of respiratory syncytial virus disease. Pediatr
Pulmonol 2000;30:131–138.
19. Schwarze J, Cieslewicz G, Hamelmann E, Joetham A, Shultz LD,
Lamers MC, Gelfand EW. IL-5 and eosinophils are essential for
the development of airway hyperresponsiveness following acute
respiratory syncytial virus infection. J Immunol 1999;162:2997–
3004.
20. Schwarze J, Cieslewicz G, Joetham A, Ikemura T, Mäkelä MJ,
Dakhama A, Shultz LD, Lamers MC, Gelfand EW. Critical roles
for interleukin-4 and interleukin-5 during respiratory syncytial
virus infection in the development of airway hyperresponsiveness
after airway sensitization. Am J Respir Crit Care Med
2000;162:380–386.
21. Nakayama T, Sonoda S, Urano T, Osano M, Maehara N, Sasaki K,
Hayatsu E, Makino S. Interferon production during the course of
Mycoplasma pneumoniae infection. Pediatr Infect Dis J 1992;11:
72–77.
22. Koh YY, Park Y, Lee HJ, Kim CK. Levels of interleukin-2,
interferon-g, and interleukin-4 in bronchoalveolar lavage fluid
from patients with Mycoplasma pneumonia: implication of ten-
dency toward increased immunoglobulin E production. Pediatrics
2001;107:39.
23. Hardy RD, Jafri HS, Olsen K, Wordemann M, Hatfield J, Rogers
BB, Patel P, Duffy L, Cassell G, McCracken GH, Ramilo O.
Elevated cytokine and chemokine levels and prolonged pulmon-
ary airflow resistance in a murine Mycoplasma pneumoniae

pneumonia model: a microbiologic, histologic, immunologic,
and respiratory plethysmographic profile. Infect Immun 2001;69:
3869–3876.
24. Martin RJ, Wei Chu H, Honour JM, Harbeck RJ. Airway
inflammation and bronchial hyperresponsiveness after Myco-
plasma pneumoniae infection in a murine model. Am J Respir
Cell Mol Biol 2001;24:577–582.
25. Abele-Horn M, Busch U, Nitzschiko H, Jacobs E, Bax R, Pfaff F,
Schaffer B, Heesemann J. Molecular approaches to diagnosis of
pulmonary diseases due to Mycoplasma pneumoniae. J Clin
Microbiol 1998;36:548–551.
26. Blasi F, Boman J, Esposito G, Melissano G, Chiesa R, Cosentini R,
Tarsia P, Tshomba Y, Betti M, Alessi M, Morelli N, Allegra L.
Chlamydia pneumoniae DNA detection in peripheral blood
mononuclear cells is predictive of vascular infection. J Infect
Dis 1999;180:2074–2076.
27. Tong CYW, Sillis M. Detection of Chlamydia pneumoniae and
Chlamydia psittaci in sputum samples by PCR. J Clin Pathol
1993;46:313–317.
Cytokines in Mycoplasma pneumoniae Infection 127
28. Thomson RB. Laboratory diagnosis of respiratory infections. Curr
Opin Infect Dis 1999;12:115–119.
29. Nystad W, Skrondal A, Njä F, Hetlevik Ø, Carlsen KH, Magnus P.
Recurrent respiratory tract infections during the first 3 years of life
and atopy at school age. Allergy 1998;53:1189–1194.
30. Schaffner E, Opitz O, Pietsch K, Bauer G, Ehlers S, Jacobs E.
Human pathogenic Mycoplasma species induce cytokine gene
expression in Epstein-Barr virus (EBV)-positive lymphoblastoid
cell lines. Microb Pathog 1998;24:257–262.
31. Kita M, Ohmoto Y, Hirai Y, Yamaguchi N, Imanishi J. Induction
of cytokines in human peripheral blood mononuclear cells by
Mycoplasmas. Microbiol Immunol 1992;36:507–516.
32. Makhoul N, Merchav S, Tatarsky I, Naot Y. Mycoplasma-induced
in vitro production of interleukin-2 and colony-stimulating
activity. Isr J Med Sci 1987;23:480–484.
33. Aray S, Munakata T, Kuwano K. Mycoplasma interaction
with lymphocytes and phagocytes: role of hydrogen peroxide
released from M. pneumoniae. Yale J Biol Med 1983;56:631–
638.