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Isolation of Mycoplasma pneumoniae from pleural fluid
DIAGN MICROBIOLINFECTDIS 1991;14:443-445
443
CASE REPORT
Isolation of Mycoplasma pneumoniae from Pleural Fluid Vivian G. Loo, Susan Richardson, and Patricia Quinn
We describe an unusual case of Mycoplasma pneumoniae infection that presented as a lobar pneumonia and pleural effu-
sion. Mycoplasma pneumoniae was isolated from the pleural fluid of this patient.
INTRODUCTION
tient was prescribed amoxicillin 250 mg p . o . t . i . d . , but his clinical status deteriorated with increased shortness of breath and persistent fever. A chest roentgenogram was done which prompted his admission to hospital. On physical examination, the patient looked unwell but was not in respiratory distress. His blood pressure was 105/65 rnm Hg, oral temperature was 38.5°C, pulse rate was 80/rnin, and respiratory rate was 22 breaths/rain. The chest examination revealed dullness to percussion, decreased tactile fremitus, decreased breath sounds, and bronchial breathing in the left lower posterior hemithorax. The remainder of the physical examination was unremarkable. Laboratory examination revealed the following: a peripheral white cell count of 9200/mm 3 with a differential of 76% neutrophils, 15% lymphocytes, and 9% monocytes, and the hemoglobin was 120 g/dl. The Westergren sedimentation rate was 62 mmYhr. The admission chest roentgenogram showed a left lower lobe opacification associated with air bronchograms. In addition, a pleural fluid collection was seen layering laterally along the left hemithorax on the left lateral decubitus film. Arterial blood gas analysis with the patient breathing room air revealed a Po2 of 46 mm Hg, PCO2 of 36 mm Hg, and pH of 7.47. The patient was started on cefuroxime 75 mg/kg/day intravenously. On the second day of hospitalization, a diagnostic left thoracentesis was performed, and 5 ml of serous fluid was removed. Laboratory analysis revealed a protein of 46 g/L, glucose of 5.1 mmol/L (concomitant serum protein of 83 g/L and serum glucose of 5.9 mmoFL), and a leukocyte count of 5760/mm 3
Mycoplasma pneumoniae has been recognized as an important pathogen in community-acquired pneumonias in children, adolescents, and young adults. It has been estimated that pneumonia develops in only 3%-10% of patients infected with M. pneumoniae (Cassell and Cole, 1981). Although severe nonrespiratory complications can also occur, Mycoplasma infection is often mild and self-limited in the majority of people, and thus is often unsuspected in those with atypical manifestations (Cassell and Cole, 1981). The following is a case report that delineates the unusual clinical presentation of a patient with serologic and culture-proven M. pneumoniae pneumonia and pleural effusion.
CASE REPORT On 15 August 1990, a previously healthy 12-yearold boy was admitted because of a 1-week history of a nonproductive cough and fever of 39.4°C orally. He had an associated headache, anorexia, and lethargy. Four days prior to admission, his family physician diagnosed bronchitis and sinusitis. The paFrom the Department of Microbiology,Hospital for Sick Children and Universityof Toronto, Toronto, Ontario, Canada. Address reprint requests to Dr. Susan Richardson, Department of Microbiology,Hospital for Sick Children, 555 UniversityAvenue, Room 7148, Toronto, Ontario, M5G 1X8, Canada. Received 18 February 1991; revised and accepted 2 April 1991. © 1991 Elsevier Science PublishingCo., Inc. 655 Avenue of the Americas, New York, NY 10010 0732-8893/91/$3.50
444
with 87% lymphocytes, 11% neutrophils, and 2% monocytes. The Gram stain was negative, and aerobic and anaerobic cultures of the pleural fluid were negative for bacteria. Mycoplasma pneumoniae was isolated from pleural fluid on SP-4 agar and broth media on day 14 after receipt of the specimen. Mycoplasma pneumoniae was identified by the immunoperoxidase method (Tully et al., 1979; T'ing and Quinn, 1990) and the colonies were hemadsorption positive. The blood culture was negative, but a sputum culture was not obtained. Cold agglutinins were negative on admission. The patient's Mycoplasma complement fixation titer was 1:128 on admission, which was not repeated. A skin test with 5 TU of purified protein derivative was negative. The patient remained febrile for the next 3 days in hospital and then defervesced. He showed progressive clinical improvement with decreased shortness of breath and diminished cough. He was discharged after 10 days of cefuroxime therapy and never received erythromycin. The isolation of M. pneumoniae did not occur until after the patient was discharged from hospital. A chest roentgenogram obtained 2 weeks after discharge showed that the left lower lobe pneumonia was much improved, but still had not fully resolved. The associated mild pleural reaction was also resolving. A follow-up examination at 8 weeks postdischarge revealed the patient to be asymptomatic, and his chest roentgenogram showed complete resolution of the pneumonia and pleural effusion. DISCUSSION
Mycoplasma pneumoniae pneumonia is usually acquired via inhalation of infected aerosols with an incubation period of - 1 - 2 weeks. It has now been recognized that attachment of the organism to the respiratory epithelium precedes cell damage (Cassell and Cole, 1981). Pneumonia is an important manifestation of M. pneumoniae infection. The main clinical manifestations include a nonproductive cough (97%), fever (85%), chills (32%), chest pain (25%), and dyspnea (17%) (Mansel et al., 1989). The radiographic appearance of M. pneumoniae pneumonia is variable, but the usual pattern is a unilateral "patchy" pneumonitis. Involvement occurs usually in the lower
V.G. Loo et al.
lobes, with 66% of patients having disease in one or both lower lobes (Mansel et al., 1989). Occasionally, lobar involvement is demonstrable. Pleural effusions were formerly believed to be infrequent in mycoplasmal infections and it has been stated that the presence of a pleural effusion should suggest a different diagnosis (Cassell and Cole, 1981). Fine et al. (1970) prospectively investigated the frequency of pleural effusions in Mycoplasma pneumonias through the use of serial posteroanterior and lateral roentgenograms with the addition of lateral decubitus views. They found that pleural effusions were seen in six (20%) of 29 pneumonias with elevated titers to M. pneumoniae. Mansel et al. (1989) retrospectively reviewed all cases of M. pneumoniae pneumonia documented at the Mayo Clinic over a 14-year period. They found eight (5.4%) of their 148 patients had evidence of pleural effusion using standard posterior-anterior and lateral chest roentgenograms. Cases of M. pneumoniae pneumonia with pleural effusions have been described (Nagayama et al., 1987 and 1990; Chester et al., 1975), but the organism has only been isolated from pleural fluid in three pediatric cases from Japan (Nagayama et al., 1987 and 1990). It is believed that pleural effusions result from direct invasion of the organism (Nagayama et al., 1987). Effusions usually are exudative with a normal glucose and variable number of polymorphonuclear leukocytes and monocytes (Tuazon and Murray, 1989). Erythromycin and tetracycline have been the mainstay of treatment. Mycoplasma pneumoniae has been shown to be susceptible in vitro to both agents (Jao and Finland, 1967). Furthermore, it has been demonstrated that, in vitro, the penicillins are inactive against M. pneumoniae (Jao and Finland, 1967). Cephalosporins, such as cephaloridine and cephalothin, are active only at high concentrations (Jao and Finland, 1967). Thus, the patient probably had a spontaneous resolution of his M. pneumoniae infection as he was not treated with an effective agent. This case illustrates that the respiratory presentation of M. pneumoniae is variable and its role as an etiologic agent should not be eliminated because of the presence of pleural effusions.
The authorsacknowledgethe technicalassistanceof Cecilia T'ng.
REFERENCES
Cassell GH, Cole BC (1981) Mycoplasmas as agents of human disease. N Eng J Med 304:80-89. Chester A, Kane J, Gragusi V (1975) Mycoplasma pneumonia with bilateral pleural effusions. Am Rev Respir Dis 112:451-456. Fine NL, Smith LR, Sheedy PF (1970) Frequency of pleural effusions in Mycoplasma and viral pneumonias. N Engl J Med 283:790-793.
Jao RL, Finland M (1967) Susceptibility of M. pneumoniae to 21 antibiotics in vitro. Am J Med Sci 253:639~50. Mansel JK, Rosenow EC III, Smith TF, et al. (1989) Mycoplasma pneumoniae pneumonia. Chest 95:639-646. Nagayama Y, Sakurai N, Tamai K, et al. (1987) Isolation of M. pneumoniae from pleural fluid and/or cerebrospinal fluid: report of four cases. Scand J Infect Dis 19:521524.
Mycoplasma pneumoniae Pneumonia and Pleural Effusion
Nagayama Y, Sakurai N, Yamamoto K (1990) Clinical observations of children with pleuropneumonia due to Mycoplasma pneumoniae. Pediatr Pulmonol 8:182-187. T'ing C, Quinn PA (1990) Modified immunoperoxidase assay for direct identification and serotyping of mycoplasma and ureaplasma colonies. Zentralbl Bakteriol MikrobioI Hyg Suppl 20:793-795.
445
Tuazon CU, Murray HW (1989) Atypical pneumonias. In Respiratory Infections: diagnosis and management. Ed, JE Pennington. New York: Raven, pp 341-363. Tully TG, Rose DL, Witcomb RE, et al. (1979) Enhanced isolation of Mycoplasma pneumoniae from throat washing with a newly modified culture medium. J Infect Dis 139:478-482.
443
CASE REPORT
Isolation of Mycoplasma pneumoniae from Pleural Fluid Vivian G. Loo, Susan Richardson, and Patricia Quinn
We describe an unusual case of Mycoplasma pneumoniae infection that presented as a lobar pneumonia and pleural effu-
sion. Mycoplasma pneumoniae was isolated from the pleural fluid of this patient.
INTRODUCTION
tient was prescribed amoxicillin 250 mg p . o . t . i . d . , but his clinical status deteriorated with increased shortness of breath and persistent fever. A chest roentgenogram was done which prompted his admission to hospital. On physical examination, the patient looked unwell but was not in respiratory distress. His blood pressure was 105/65 rnm Hg, oral temperature was 38.5°C, pulse rate was 80/rnin, and respiratory rate was 22 breaths/rain. The chest examination revealed dullness to percussion, decreased tactile fremitus, decreased breath sounds, and bronchial breathing in the left lower posterior hemithorax. The remainder of the physical examination was unremarkable. Laboratory examination revealed the following: a peripheral white cell count of 9200/mm 3 with a differential of 76% neutrophils, 15% lymphocytes, and 9% monocytes, and the hemoglobin was 120 g/dl. The Westergren sedimentation rate was 62 mmYhr. The admission chest roentgenogram showed a left lower lobe opacification associated with air bronchograms. In addition, a pleural fluid collection was seen layering laterally along the left hemithorax on the left lateral decubitus film. Arterial blood gas analysis with the patient breathing room air revealed a Po2 of 46 mm Hg, PCO2 of 36 mm Hg, and pH of 7.47. The patient was started on cefuroxime 75 mg/kg/day intravenously. On the second day of hospitalization, a diagnostic left thoracentesis was performed, and 5 ml of serous fluid was removed. Laboratory analysis revealed a protein of 46 g/L, glucose of 5.1 mmol/L (concomitant serum protein of 83 g/L and serum glucose of 5.9 mmoFL), and a leukocyte count of 5760/mm 3
Mycoplasma pneumoniae has been recognized as an important pathogen in community-acquired pneumonias in children, adolescents, and young adults. It has been estimated that pneumonia develops in only 3%-10% of patients infected with M. pneumoniae (Cassell and Cole, 1981). Although severe nonrespiratory complications can also occur, Mycoplasma infection is often mild and self-limited in the majority of people, and thus is often unsuspected in those with atypical manifestations (Cassell and Cole, 1981). The following is a case report that delineates the unusual clinical presentation of a patient with serologic and culture-proven M. pneumoniae pneumonia and pleural effusion.
CASE REPORT On 15 August 1990, a previously healthy 12-yearold boy was admitted because of a 1-week history of a nonproductive cough and fever of 39.4°C orally. He had an associated headache, anorexia, and lethargy. Four days prior to admission, his family physician diagnosed bronchitis and sinusitis. The paFrom the Department of Microbiology,Hospital for Sick Children and Universityof Toronto, Toronto, Ontario, Canada. Address reprint requests to Dr. Susan Richardson, Department of Microbiology,Hospital for Sick Children, 555 UniversityAvenue, Room 7148, Toronto, Ontario, M5G 1X8, Canada. Received 18 February 1991; revised and accepted 2 April 1991. © 1991 Elsevier Science PublishingCo., Inc. 655 Avenue of the Americas, New York, NY 10010 0732-8893/91/$3.50
444
with 87% lymphocytes, 11% neutrophils, and 2% monocytes. The Gram stain was negative, and aerobic and anaerobic cultures of the pleural fluid were negative for bacteria. Mycoplasma pneumoniae was isolated from pleural fluid on SP-4 agar and broth media on day 14 after receipt of the specimen. Mycoplasma pneumoniae was identified by the immunoperoxidase method (Tully et al., 1979; T'ing and Quinn, 1990) and the colonies were hemadsorption positive. The blood culture was negative, but a sputum culture was not obtained. Cold agglutinins were negative on admission. The patient's Mycoplasma complement fixation titer was 1:128 on admission, which was not repeated. A skin test with 5 TU of purified protein derivative was negative. The patient remained febrile for the next 3 days in hospital and then defervesced. He showed progressive clinical improvement with decreased shortness of breath and diminished cough. He was discharged after 10 days of cefuroxime therapy and never received erythromycin. The isolation of M. pneumoniae did not occur until after the patient was discharged from hospital. A chest roentgenogram obtained 2 weeks after discharge showed that the left lower lobe pneumonia was much improved, but still had not fully resolved. The associated mild pleural reaction was also resolving. A follow-up examination at 8 weeks postdischarge revealed the patient to be asymptomatic, and his chest roentgenogram showed complete resolution of the pneumonia and pleural effusion. DISCUSSION
Mycoplasma pneumoniae pneumonia is usually acquired via inhalation of infected aerosols with an incubation period of - 1 - 2 weeks. It has now been recognized that attachment of the organism to the respiratory epithelium precedes cell damage (Cassell and Cole, 1981). Pneumonia is an important manifestation of M. pneumoniae infection. The main clinical manifestations include a nonproductive cough (97%), fever (85%), chills (32%), chest pain (25%), and dyspnea (17%) (Mansel et al., 1989). The radiographic appearance of M. pneumoniae pneumonia is variable, but the usual pattern is a unilateral "patchy" pneumonitis. Involvement occurs usually in the lower
V.G. Loo et al.
lobes, with 66% of patients having disease in one or both lower lobes (Mansel et al., 1989). Occasionally, lobar involvement is demonstrable. Pleural effusions were formerly believed to be infrequent in mycoplasmal infections and it has been stated that the presence of a pleural effusion should suggest a different diagnosis (Cassell and Cole, 1981). Fine et al. (1970) prospectively investigated the frequency of pleural effusions in Mycoplasma pneumonias through the use of serial posteroanterior and lateral roentgenograms with the addition of lateral decubitus views. They found that pleural effusions were seen in six (20%) of 29 pneumonias with elevated titers to M. pneumoniae. Mansel et al. (1989) retrospectively reviewed all cases of M. pneumoniae pneumonia documented at the Mayo Clinic over a 14-year period. They found eight (5.4%) of their 148 patients had evidence of pleural effusion using standard posterior-anterior and lateral chest roentgenograms. Cases of M. pneumoniae pneumonia with pleural effusions have been described (Nagayama et al., 1987 and 1990; Chester et al., 1975), but the organism has only been isolated from pleural fluid in three pediatric cases from Japan (Nagayama et al., 1987 and 1990). It is believed that pleural effusions result from direct invasion of the organism (Nagayama et al., 1987). Effusions usually are exudative with a normal glucose and variable number of polymorphonuclear leukocytes and monocytes (Tuazon and Murray, 1989). Erythromycin and tetracycline have been the mainstay of treatment. Mycoplasma pneumoniae has been shown to be susceptible in vitro to both agents (Jao and Finland, 1967). Furthermore, it has been demonstrated that, in vitro, the penicillins are inactive against M. pneumoniae (Jao and Finland, 1967). Cephalosporins, such as cephaloridine and cephalothin, are active only at high concentrations (Jao and Finland, 1967). Thus, the patient probably had a spontaneous resolution of his M. pneumoniae infection as he was not treated with an effective agent. This case illustrates that the respiratory presentation of M. pneumoniae is variable and its role as an etiologic agent should not be eliminated because of the presence of pleural effusions.
The authorsacknowledgethe technicalassistanceof Cecilia T'ng.
REFERENCES
Cassell GH, Cole BC (1981) Mycoplasmas as agents of human disease. N Eng J Med 304:80-89. Chester A, Kane J, Gragusi V (1975) Mycoplasma pneumonia with bilateral pleural effusions. Am Rev Respir Dis 112:451-456. Fine NL, Smith LR, Sheedy PF (1970) Frequency of pleural effusions in Mycoplasma and viral pneumonias. N Engl J Med 283:790-793.
Jao RL, Finland M (1967) Susceptibility of M. pneumoniae to 21 antibiotics in vitro. Am J Med Sci 253:639~50. Mansel JK, Rosenow EC III, Smith TF, et al. (1989) Mycoplasma pneumoniae pneumonia. Chest 95:639-646. Nagayama Y, Sakurai N, Tamai K, et al. (1987) Isolation of M. pneumoniae from pleural fluid and/or cerebrospinal fluid: report of four cases. Scand J Infect Dis 19:521524.
Mycoplasma pneumoniae Pneumonia and Pleural Effusion
Nagayama Y, Sakurai N, Yamamoto K (1990) Clinical observations of children with pleuropneumonia due to Mycoplasma pneumoniae. Pediatr Pulmonol 8:182-187. T'ing C, Quinn PA (1990) Modified immunoperoxidase assay for direct identification and serotyping of mycoplasma and ureaplasma colonies. Zentralbl Bakteriol MikrobioI Hyg Suppl 20:793-795.
445
Tuazon CU, Murray HW (1989) Atypical pneumonias. In Respiratory Infections: diagnosis and management. Ed, JE Pennington. New York: Raven, pp 341-363. Tully TG, Rose DL, Witcomb RE, et al. (1979) Enhanced isolation of Mycoplasma pneumoniae from throat washing with a newly modified culture medium. J Infect Dis 139:478-482.