MYCOPLASMA PNEUMONIA

FROM THE FAMILY OF MOLLICUTES

李爱，杨乐乐，利华，邢勇芳
INTRODUCTION

Mycoplasma pneumonia is a bacteria that can infect humans. It usually

causes upper respiratory tract infections but can also cause pneumonia, and
it is one of the most common causes of atypical pneumonia in the United
States. Many extrapulmonary infections have been attributed to
Mycoplasma pneumoniae infections. However, a causal link is yet to be
established.
• Reimann first described mycoplasmal pneumonia after observing a series
of seven patients with marked constitutional symptoms and termed it
‘primary atypical pneumonia.’
• Mycoplasmas are the smallest and simplest self-replicating
bacteria. The mycoplasma cell contains the minimum set of
organelles essential for growth and replication: a plasma
membrane, ribosomes, and a genome consisting of a double-
stranded circular DNA molecule . Unlike all other prokaryotes,
the mycoplasmas have no cell walls, and they are
consequently placed in a separate class Mollicutes(mollis, soft;
cutis, skin). The trivial term mollicutes is frequently used as a
general term to describe any member of the class, replacing in
this respect the older term mycoplasmas.
• Mycoplasmas have been nicknamed the “crabgrass” of cell cultures because their infections are
persistent, frequently difficult to detect and diagnose, and difficult to cure. Contamination of cell
cultures by mycoplasmas presents serious problems in research laboratories and in biotechnological
industries using cell cultures. The origin of contaminating mycoplasmas is in components of the
culture medium, particularly serum, or in the flora of the technician’s mouth, spread by droplet
infection.
ETIOLOG
Y

Mycoplasma species are the smallest living organisms that can

survive alone in nature. There are over 120 Mycoplasma species;
only 13 have been isolated from humans, and only four are
known to cause disease in humans. Mycoplasma pneumoniae is
the pathogen most commonly associated with disease in humans.
It is a short rod with no cell wall; therefore, it is not visible on the
Gram stain. It can be isolated on media supplemented with
serum. However, it is fastidious, and isolation is not usually
performed in clinical laboratories.It requires special culture media
and also takes a long time for growth. Due to these reasons, it is
not routinely cultured. It is excreted from the respiratory tract
after many weeks of acute infection; therefore, isolation of the
organism is not specific for acute infection at that particular time.
 EPIDEMIOLOG
Y

• M. pneumoniae is now considered a common cause of community-acquired pneumonia and is

transmitted from person to person via respiratory droplets during close contact. It has an
incubation period that ranges between 2 to 3 weeks. Like most respiratory pathogens, infection
usually occurs during the winter months but can happen year-round. Estimates show that
around 1% of the population of the United States is infected annually. Incidence may be much
higher since infection can be subclinical or cause milder disease that does not require
hospitalization. Outbreaks of mycoplasma infection occur in military recruits, hospitals, nursing
homes, and other long-term care facilities.Only 5 to 10% of people infected with Mycoplasma
develop pneumonia. It causes upper and lower respiratory tract infections in all age groups,
particularly more than 5 years and less than 40 years of age
 PATHOPHYSIOLOGY

M. pneumoniae has adherence proteins that can attach to epithelial

membranes, particularly the respiratory tract epithelium. Once attached, M.
pneumoniae produces hydrogen peroxide and superoxide, causing injury to
epithelial cells and their associated cilia. Antibodies produced against M.
pneumoniae may act as autoantibodies since they crossreact with human brain
cells and RBCs. The pathogenesis of Mycoplasma pneumoniae includes the
activation of inflammatory cytokines.

Mycoplasma pneumoniae has a gliding movement and specific tip organelles

that help in burrowing between cilia in respiratory epithelium, leading to the
sloughing of the respiratory epithelial cells. The prolonged refractory cough is
considered to be due to inhibition of the ciliary movement.
• Mycoplasma pneumoniae causes extrapulmonary illnesses and respiratory
tract infection, including immune thrombocytopenic purpura, acute
hepatitis, autoimmune hemolytic anemia, arthritis, and transverse myelitis
HISTORY AND PHYSICAL
FINDINGS
Many M. pneumoniae infections are asymptomatic. Patient symptoms are typically more significant
than objective findings on physical exam. Disease onset is gradual, and patients can initially complain
of headaches, malaise, and low-grade fever. A nagging cough is usually the most prominent respiratory
feature. Chest soreness from coughing is common. Wheezing can also occur. Other respiratory
symptoms include pharyngitis, rhinorrhea, and ear pain. Pleural effusion occurs in 15% to 20% of
patients who develop pneumonia and may predict increased morbidity and mortality. Most cases of
pneumonia are mild and self-limited. However, a more fulminant course can occur. Extrapulmonary
features may help suggest the diagnosis and include hemolysis, skin rash, joint pain, gastrointestinal
(GI) symptoms, and heart disease. These occur in less than 5% to 10% of patients. Hemolysis occurs
due to IgM antibodies producing a cold agglutinin reaction. Cardiac involvement includes conduction
abnormalities on ECG, congestive heart failure, and chest pain.
• Physical examination findings are often minimal. Chest auscultation can be normal even if
pneumonia is present. Scattered rales, wheezes can present later in the course of the disease.
Sinus tenderness and mild erythema of the posterior pharynx may also be found on physical
examination. A mild erythematous maculopapular or vesicular rash may also be found. Bullous
myringitis, the presence of vesicles or bulls on the tympanic membrane, can be seen in some
cases.
EVALUATION

There are no specific clinical or radiological findings to mycoplasma pneumonia that can differentiate it from other causes of
atypical pneumonia. However, patients tend to have a more gradual onset of disease, more multisystem involvement, and a
normal white blood cell (WBC) count. Patients usually present in an outpatient setting, and microbial diagnosis is not usually
performed for outpatients with community-acquired pneumonia since empiric treatment is usually successful. When available,
PCR can be done rapidly and is the test of choice. Testing for cold agglutinins can sometimes support a clinical diagnosis when a
rapid diagnosis must be made. M. pneumoniae lacks a cell wall and is fastidious; therefore, gram stain and cultures are not useful
for the diagnosis of these organisms.Mycoplasma pneumoniae is difficult to culture; a special culture media and 7 to 21 days must
culture it. Serologic tests like complement fixation, enzyme-linked immunoassay, immunochromatography, and hemagglutination
have acceptable sensitivity and specificity. Those serologic tests which show a four-fold greater increase or decrease in paired sera
titers or a single tire of more than 1: 32 are diagnostic of Mycoplasma pneumoniae.

Hemolysis is found in most patients with pneumonia and causes a positive Coomb’s test and an elevated reticulocyte count. Cold
agglutinin titers are elevated in more than 50% of patients with mycoplasma disease. However, this is not specific to Mycoplasma
infections and can be found in patients with viral pneumonia or infectious mononucleosis due to EBV or CMV. WBC count is normal
in 75% to 90% of cases. The most common chest x-ray findings are a reticulonodular pattern or patchy areas of consolidation;
these can be unilateral or bilateral and are more prominent in the lower lobes.
• Eosinophil cationic protein has been found to be elevated in patients with mycoplasma infection and asthma. It is believed that
this protein damages the epithelium in the airways and induces hypersensitivity of the bronchial smooth muscle. However,
more studies are required before its use as a diagnostic marker becomes universal
TREATMENT AND MANAGEMENT

Gradual onset of symptoms combined with extrapulmonary involvement and a normal WBC count points
to atypical pneumonia. Most patients with M. pneumoniae pneumonia present in outpatient settings, and
treatment is often with empiric antibiotics for atypical pneumonia. Note that many patients may undergo a
period of symptomatic management before seeking medical attention and/or receiving antibiotic
treatment.
• Treatment of M. pneumoniae includes macrolides, doxycycline, or fluoroquinolones. Azithromycin is the
most frequently used antibiotic and is usually prescribed for 5 days (500 mg for the first dose, followed
by 250 mg daily for 4 days). Patients receiving doxycycline or fluoroquinolones should be given 7 to 14
days of treatment.Macrolide resistance continues to emerge, so if a patient is not responding to
macrolides, other antibiotics can be given. Routine antibiotic prophylaxis is not required for the exposed
contacts except for those prone to serious mycoplasmal infection, like patients with sickle cell disease or
antibody deficiency. For prophylaxis, doxycycline or macrolides are used.
• DIFFERENTIAL DIAGNOSIS
• Diagnostic Considerations
• M. pneumoniae is a prevalent cause of community-acquired pneumonia in healthy individuals under the age
of 40. Large outbreaks are known to occur in the late summer months and early fall. The infection is also
more common in populations that live in close quarters like prisoners and military personnel. Unlike other
viral pneumonia, the incubation period for mycoplasma is 14 to 21 days. The key feature to the diagnosis is
the absence of a wet cough. Other diagnoses that can be confused with mycoplasma pneumonia include the
following:
• Aspiration pneumonitis and pneumonia
• Bacterial pneumonia
• Chlamydia pneumoniae
• Coxiella burnetii infection
• Empyema
• Legionella pneumophila
• Lung abscess
• Pediatric pneumonia
• Q fever
• Viral pneumonia
• PROGNOSIS
• In most patients who receive prompt treatment, the prognosis is excellent, and patients are expected
to make a full recovery. The symptoms and signs of pneumonia usually resolve within a few days
without any complications. However, in young children, the infection can be associated with severe
pneumonia, and in patients with sickle cell anemia, it may be associated with acute chest syndrome.
The immunity after a Mycoplasma pneumoniae infection is short-lived.
Complications
Even though mycoplasma pneumonia in most people is a benign infection, it can lead to several
complications, especially in children and the elderly. The list of complications includes the following:
ARDS
Bronchiolitis obliterans
Lobar consolidation
Lung abscess
Necrotizing pneumonitis
Pleural effusion (15% to 20%), empyema (rare)
• Respiratory failure
Extrapulmonary Complications
Mycoplasma can also be associated with severe extrapulmonary complications. These
complications may be due to the organism itself; it may be triggered by the resulting
immunological response to the bacteria. The list of extrapulmonary complications includes:
Myocardium problems: Conduction abnormalities, heart blocks, or rhythm disturbances.
Both pericarditis and congestive heart failure have been reported in young people.
The central nervous system (CNS): Rare but can include encephalitis, transverse myelitis,
aseptic meningitis, and cerebellar ataxia. These CNS complications are more common in
children.
Hematologic problems: Hemolytic anemia due to cross-reactivity of antibodies to M.
Pneumoniae antigens to red blood cells. The hemolysis is mild.
Dermatology: M. Pneumoniae infection may be associated with urticaria, erythema
nodosum, or steven johnson syndrome. The skin lesions are seen in about one-third of
patients.
Musculoskeletal problems include myalgia and arthralgia. Septic arthritis is very rare. Rare
cases of rhabdomyolysis have been reported.
Gastrointestinal (GI) dysfunction include pancreatitis or hepatitis and are linked to the
circulating IgM antibodies.
Ophthalmologic problems include conjunctivitis, optic papillitis, anterior uveitis, and cranial
neuropathies.
• Kidney problems are rare and may result in glomerulonephritis due to immune complex
precipitation in the glomeruli.
Deterrence and Patient Education
• Patients need counsel regarding infection prevention. This includes information regarding getting the
pneumococcal vaccine, as well as the influenza vaccine, which in addition to helping prevent
influenza, can impede possible complications, such as pneumonia. If the patient smokes, they should
receive strong counsel and support to stop, as it can preclude pneumonia and other health concerns.
Addressing any underlying conditions (e.g., asthma, diabetes, congestive heart failure) can also help
prevent pneumonia.
THANKYOU