Original article
Clinical features, risk factors and treatment of fulminant Mycoplasma pneumoniae pneumonia: A review of the Japanese literature

https://doi.org/10.1016/j.jiac.2013.09.009Get rights and content

Abstract

Mycoplasma pneumoniae (MP) is one of the most common causes of community-acquired pneumonia in children and young adults. Although MP sometimes causes self-limiting pneumonia, severe and fulminant cases with hypoxia occur, but their clinical features have rarely been reported. This study aimed to reveal the clinical manifestations, risk factors, and treatment of fulminant MP pneumonia (MPP). Using PubMed and abstracts from the proceedings of several domestic Japanese academic societies, we reviewed the Japanese and English literature for cases of fulminant or severe MPP reported in Japan. All clinical information such as sex, age, underlying diseases, clinical symptoms, clinical course, laboratory and radiological findings, and treatment was collected and analyzed. In total, 52 fulminant MPP cases were reported between September, 1979 and February, 2010. The dominant population of fulminant MPP was young adults without severe underlying diseases. Cough (97.3%), fever (100.0%), and dyspnea (83.3%) with diffuse abnormal findings in radiological examinations were noted. Antibiotics without anti-mycoplasmal activity were used in 32 cases (61.5%) as initial treatment prior to the onset of hypoxia. Anti-mycoplasmal drugs were appropriately used in 41 cases (78.8%) after onset of respiratory failure with steroids (23 cases, 45.1%) and effective. The majority of patients improved within 3–5 days after steroid administration. There were only 2 fatal cases. Although this small retrospective study did not reveal the apparent risk factors of fulminant MPP, initial inappropriate use of antibiotics may be a risk factor, and early administration of appropriate anti-mycoplasmal drugs with steroids as a cellular immune suppressor is required.

Introduction

Mycoplasma pneumoniae is one of the most common causes of atypical pneumonia worldwide occurring in all populations especially youths. Transmission of M. pneumoniae occurs via infected respiratory droplets during close contact between the source and the recipient. Atypical pneumonia is considered to account for 7–20% of community-acquired pneumonia (CAP) [1], [2]. Previous Japanese epidemiological studies of CAP have also indicated a prevalence of 5.2–15.4%, which does not differ from the data of studies carried out in other countries [3], [4], [5]. The actual incidence of M. pneumoniae pneumonia (MPP), however, may be higher in patients with mild symptoms that can be managed without hospital admission. Commonly, patients with mycoplasma respiratory infection may have nonproductive, persistent cough, pharyngitis, rhinorrhea, and occasional extrapulmonary manifestations such as hemolysis, skin reactions (e.g. the Stevens–Johnson syndrome), and central nervous system complications. Although MPP is sometimes self-limiting, and macrolides are effective against it, numerous fulminant cases of MPP, including that of acute respiratory distress syndrome (ARDS), have been reported to date [6], [7]. The major clinical manifestation of fulminant MPP is respiratory failure with diffuse consolidation or an abnormal interstitial pattern that can be observed on a chest radiograph. The incidence of fulminant MPP is relatively rare despite the high prevalence of M. pneumoniae infection, and its etiology has not been fully described. The clinical features of fulminant MPP have not been clearly elucidated either.

We reviewed 52 cases of fulminant MPP with respiratory failure; we obtained their reports from multiple institutes and clinics in Japan and analyzed their clinical characteristics, risk factors, and treatment.

Section snippets

Case collection

Using PubMed and abstracts from the proceedings of several domestic Japanese academic societies, we searched the Japanese and English literature for cases of fulminant or severe MPP reported in Japan before February, 2010. Fulminant MPP was defined as the apparent presence of MP infection with hypoxia. All cases must fulfilled following conditions; (1) the patients should be diagnosed with MPP after obtaining positive findings from any of microbiological laboratory tests such as culturing or

Patient characteristics

We found and analyzed 52 cases in the literature between September, 1979 and February, 2010. All cases involved Japanese patients and MP infection was diagnosed by serological antibody tests such as PA, CF, and IHA. PA, CF, and IHA diagnosed 15, 27, and 20 cases, respectively, and confirmed single titer elevation in 2, 3, and 4 cases, respectively. The remaining cases were diagnosed by paired titer elevation in serum samples. MP was isolated in 2 of 3 cases in which culture was attempted. No

Discussion

The incidence of respiratory failure in cases of fulminant MPP has rarely been reported despite the high prevalence of MPP [6]. Among 295 MPP cases, we have encountered only 3 patients (1.0%), which presented respiratory failure (data not published).

MPP is sometimes a self-limiting disease; however, the following are considered virulence-associated factors of MP: 1) direct interaction between human host cells caused by toxicity (e.g., adherence to bronchoepithelial cells, toxin production,

Conflicts of interest

Koichi Izumikawa received honorarium from Pfizer Japan Inc., Dainippon Sumitomo Pharma Co., Ltd., MSD K. K., Astellas Pharma Inc., Taisho Toyama Pharmaceutical Co., Ltd., and Daiichi Sankyo Co., Ltd. Yoshifumi Imamura received honorarium from Pfizer Japan Inc., Dainippon Sumitomo Pharma Co., Ltd., MSD K. K., Taisho Toyama Pharmaceutical Co., Ltd., and Daiichi Sankyo Co., Ltd. Shigeru Kohno and Katsunori Yanagihara received honorarium and research grant from Pfizer Japan Inc., Dainippon Sumitomo

Acknowledgments

We appreciated for acceptance of using data of the articles written by following authors; Naofumi Suyama, Niro Okimoto, Toshihiro Shirai, Yohsuke Miyagawa, Masamitsu Nakajima, Kohji Hashiguchi, Hiromi Tomioka, Mitsuhide Ohmichi, Haruko Taniguchi, Yosuke Aoki, Midori Fujishiro, Noboru Uchiyama, Hiroshi Yoshida, Mayumi Inoue, Shigeyuki Aoki, Shouhei Nagaoka, Maki Wakasa, Shigeki Yokoyama, Tsuneaki Shiraishi, Masahiro Miyai, Shoji Ohno, Shigeo Takizawa, Hiroshi Tanaka, Hideo Mashimoto, Nobue

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