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A Case of Mycoplasma pneumoniae Pneumonia Presented With the Dramatic Radiological Change, Suggesting the Possibility of the Host Cell-Mediated Immunity FREE TO VIEW

Hideki Makino*, MD; Haruki Kobayashi, MD; Kei Nakashima, MD; Nobuhiro Asai, MD; Naoko Katsurada, MD; Masafumi Misawa, PhD; Norihiro Kaneko, MD; Masahiro Aoshima, PhD
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Kameda Medical Center, Kamogawa, Japan

Chest. 2012;142(4_MeetingAbstracts):248A. doi:10.1378/chest.1371111
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SESSION TYPE: Infectious Disease Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: The chest radiological features of Mycoplasma pneumoniae (M. pneumonia) pneumonia are varied. The characteristics of the host cell-mediated immunity (CMI) might influence the pattern of pulmonary lesions in M. pneumoniae infection#1

CASE PRESENTATION: A previously healthy nonsmoking 40-year-old woman with two-day history of fever and productive cough was admitted to a local hospital. Two weeks before admission, her daughter had M. pneumoniae infection with mild but persistent symptoms despite of macrolide treatment. The patient was initially treated as pneumonia with a combination of azithromycin 500mg q 24hr for 3 days and IV ceftriaxone 2g q24hr followed by sulbactam/ampicillin 3g q6hr for one week. However, her clinical symptoms, desaturation with persistent high fever and chest radiological findings were refractory to the treatment and she was referred to our hospital. On examination, there were markedly diminished breath sounds over the left lung and scattered crackle on the right lower lung. Soluble Interleulin-2 receptor (s-IL2R) was remarkably elevated, and tuberculin skin test was negative. The High-resolution computed tomography (HRCT) of the chest revealed airspace consolidation and atelectasis in the left lung and mild centrilobular nodules in the right lower lung. Immediately administration of methylprednisolone 1g for three days was initiated with azithromycin, 500mg q 24hr and IV Ciprofloxacin (CPFX), 300mg q12hr. Although these resulted in a dramatic improvement of the clinical symptoms and airspace consolidation, diffuse centrilobular nodules in the left lung with wheezing remained. Gram’s stain, routine bacterial and fungal cultures were negative. The acute serum cold agglutinin titer was 1:16384 and the M pneumoniae IgG (complement fixation) was 1:64.and IgM (particle agglutination) was 1: 20480. The sputum polymerase chain reaction for determination of M pneumoniae was positive. We concluded that she had exclusive M pneumoniae pneumonia. Finally, the patient was treated with azithromycin for 14days and IV CPFX for 7days with prednisone, 40mg for 7days. Six weeks after the treatment, wheezing and chest radiological manifestation in the left lung still remained. Pulmonary function test indicated peripheral airway obstruction without airway reversibility. Moreover, HRCT on expiration revealed the mosaic pattern, indicating air trapping. These results suggested the bronchiolitis obliterans (BO), as the sequeale of M. pneumoniae pneumonia, although transbronchial lung biopsy could not elucidated the histology of BO. Bronchoalveolar lavage fluid revealed infiltration of neutrophil and lymphocyte.

DISCUSSION: Herein we describe an adult with exclusive M pneumoniae pneumonia who presented with the dramatic change of the radiological manifestations, T cell marker activation, negative tuberculin test, suggesting the possibility of the cell-mediated immunity (CMI) of the host. Her clinical course was very different from that of her daughter. In general, the chest CT findings can be divided into the two groups: one group had a predominance of nodular opacities with a centrilobular distribution and the other showed a predominance of an airspace consolidation. Our case showed airspace consolidation in the early stage, changed nodular opacities in the late stage, and demonstrated remarkable elevation of s-IL2R and reduction to the treatment, as a T cell activation marker. Negative tuberculin test might suggest the lung local CMI decline. All these findings were influenced by the treatment with corticosteroids and macrolide antibiotics, and host CMI. Corticosteroids had been successfully used for both radiological types of M. pneumoniae infection for the purpose of anti-inflammatory effects, without no strong evidence. Macrolide antibiotics also had been used not only for direct antimicrobial activity but also anti-inflammatory effects. These treatment might lead to a successful outcome in our case.

CONCLUSIONS: Radiological manifestations of M. pneumoniae infection could be influenced by both the treatment and the host CMI response.

1) Eur Respir J, 1996, 9, 669-672

DISCLOSURE: The following authors have nothing to disclose: Hideki Makino, Haruki Kobayashi, Kei Nakashima, Nobuhiro Asai, Naoko Katsurada, Masafumi Misawa, Norihiro Kaneko, Masahiro Aoshima

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Kameda Medical Center, Kamogawa, Japan




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