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Home , Coinfection, Mycoplasma, Mycoplasma pneumoniae, Pneumococcal infection, Streptococcus, Streptococcus pneumoniae

Arch Dis Child 2000;83:413–414 413

Streptococcus pneumoniae and Arch Dis Child: first published as 10.1136/adc.83.5.413 on 1 November 2000. Downloaded from pneumoniae coinfection in community acquired

P Toikka, T Juvén, R Virkki, M Leinonen, J Mertsola, O Ruuskanen

Abstract some cases, the complement fixation (CF) test The characteristics of nine children with and/or cold haemagglutinin tests were carried community acquired pneumonia with evi- out according to standard methods. For detec- dence of pneumoniae and tion of S pneumoniae , pneumolysin coinfection are IgG and pneumolysin immune described. complexes as well as C IgG (Arch Dis Child 2000;83:413–414) antibodies and immune complexes were measured in acute phase and convalescent Keywords: ; Mycoplasma 2 pneumoniae; pneumonia; coinfection phase serum samples. cultures were obtained from two patients. The methods have been described previously.2 Mixed viral–bacterial as well as viral–viral infections are not uncommon in childhood pneumonia, and dual bacterial infections have also been described.1 We Results describe the clinical characteristics and out- Pneumonia caused by M pneumoniae was diag- come of nine children with community ac- nosed in 17 patients, and pneumonia caused by quired pneumonia with serological evidence of S pneumoniae in 93 patients. Of these, evidence both Streptococcus pneumoniae and Mycoplasma of coinfection of M pneumoniae and S pneumo- Department of pneumoniae infections. niae was found in nine patients (table 1). Three Pediatrics, Turku of the nine children with coinfection also had University Hospital, Patients and methods evidence of viral infection (, influ- Vähä Hämeenkatu 1 A Between 1 January 1993 and 31 December enza A , and human herpes virus 6). In 3, FIN-20500 Turku, Finland 1995, the aetiology of community acquired addition, one child had evidence of H influen- P Toikka pneumonia was studied in 254 hospitalised zae infection and one had evidence of M T Juvén children at the Department of Paediatrics, catarrhalis infection as a third possible causa-

J Mertsola Turku University Hospital.2 The tive agent. All nine patients were febrile before http://adc.bmj.com/ O Ruuskanen implicated were S pneumoniae, M pneumoniae, admission (>37.5°C). Seven patients had Moraxella catarrhalis, Haemophilus influenzae, symptoms of infection. Five Department of Radiology, Turku , and pneumo- patients appeared ill. One patient had otitis University Hospital niae. The implicated were respiratory media and one had maxillary as well as R Virkki syncytial virus, rhinovirus, parainfluenza virus . All patients had alveolar infiltrations types 1, 2, and 3, adenovirus, human herpesvi- in their chest radiographs: four solely and five National Public Health rus 6, influenza A and B virus, and . with interstitial infiltrations. Five children had Institute, Oulu, Informed consent was obtained from the on September 30, 2021 by guest. Protected copyright. Finland a C reactive concentration greater than M Leinonen parents or guardians of children serving as 80 mg/l or a white blood count greater than study subjects. 15 × 109/l. In the hospital, seven patients were Correspondence to: M pneumoniae infection was identified by initially treated with â lactam (table Dr Toikka studying IgM and IgG antibodies in acute and pia.toikka@utu.fi 2), and two patients received treat- convalescent phase serum samples and/or ment. Finally, five of the nine patients received Accepted 20 July 2000 positive nasopharyngeal aspirate culture.2 In macrolide treatment either before hospitalisa- Table 1 Tests positive for Mycoplasma pneumoniae and Streptococcus pneumoniae in tion, in the hospital, or after discharge. The children with coinfection mean duration of (>37.5°C) after onset of therapy was 24.4 (SD 14.5) hours, Case Tests positive for Streptococcus ranging from 10 to 48 hours in eight patients no. Tests positive for Mycoplasma pneumoniae pneumoniae who were febrile in the hospital. Four of six 1 IgM (2, 27)*, CA (2) Pneumolysin IC patients not initially treated with a macrolide 2 IgM (33), IgG (rise†), culture (1), CA (1) Pneumolysin IC 3 IgM (27), IgG (rise), culture (1) Pneumolysin IC had respiratory symptoms or fever for up to 4 IgM (1, 30), IgG (rise), CA (1) Pneumolysin IC seven days after discharge. In two of them, the 5 IgM (1, 24), IgG (rise) Pneumolysin IC, pneumolysin symptoms disappeared after onset of macrolide IgG, C polysaccharide IgG 6 IgM (1), IgG (1) Pneumolysin IC treatment. At the follow up visit three to four 7 IgM (1, 29) C polysaccharide IgG weeks after discharge, all patients showed clini- 8 IgM (1, 26) Pneumolysin IgG 9 CF (rise) Pneumolysin IC, pneumolysin cal recovery from pneumonia, but four (of the IgG, C polysaccharide IgG eight) patients still had minor infiltrations on chest radiograph. One patient treated with *Days at which positive tests for M pneumoniae were obtained after admission. †Twofold or greater rise in titres between paired samples. and cefadroxil developed IC, immune complexes; CA, cold haemagglutinins; CF, complement fixation test. during follow up.

www.archdischild.com 414 Toikka,Juvén, Virkki, Leinonen, Mertsola, Ruuskanen

Table 2 Characteristics of children with Streptococcus pneumoniae and Mycoplasma reported four patients with severe bacterial or Arch Dis Child: first published as 10.1136/adc.83.5.413 on 1 November 2000. Downloaded from pneumoniae coinfection viral infections either following or coinciding with M pneumoniae respiratory infection. All Duration of Case Age symptoms/fever Treatment in the hospital/after Symptoms after these studies suggest that M pneumoniae, like no. (y)/sex before admission discharge discharge respiratory viruses, may predispose to second- 1 7.3/M 9 d/9 d* Penicillin/cefadroxil for a week ary bacterial infection. 2 10.5/M 3 d/3 d /erythromycin None In this study, seven patients (78%) had been 3 1.9/M 2 to 3 wk/<1 d Penicillin/penicillin Fever, cough, lethargy for 5 days ill for a week or longer before admission, 4 5.3/F 2 to 3 wk/<1 d Penicillin/penicillin‡, azithromycin Fever for 1 day supporting the view that M pneumoniae infec- 5 2.4/M 2 wk/2 wk Penicillin/penicillin§, Fever and cough for a tion probably precedes S pneumoniae infection. week 6 12.7/F 4 wk/4 wk† Azithromycin/azithromycin None In our earlier study, only 25% of 85 children 7 1.4/F 7 d/4 d Penicillin/penicillin and cough for with bacteraemic a week had had symptoms for seven or more days at 8 5.6/F 7 d/7 d /-sulpha None 10 9 3.1/F 3 d/3 d Penicillin/penicillin None the time of diagnosis. Patients with M pneumoniae pneumonia are often treated as *The patient had received a 5-day course of azithromycin before admission. outpatients.7 It is possible that an additional †The patient had received an 8-day course of cefadroxil before admission. ‡Was changed after one day because of fever. , which cannot usually §Oral penicillin treatment was changed to azithromycin after 1 week when a positive test result for be confirmed by standard methods, M pneumoniae was available. increases symptoms leading to hospitalisation Discussion in a patient with M pneumoniae pneumonia. S pneumoniae and M pneumoniae are the major bacterial causes of community acquired pneu- The study was financially supported by the Maud Kuistila monia in children, together accounting for up Foundation and the Paulo Foundation. to 60% of cases.1–3 In the present study, half of the hospitalised children with M pneumoniae 1 Ruuskanen O, Mertsola J. Childhood community-acquired pneumonia had evidence of S pneumoniae pneumonia. Semin Respir Infect 1999;14:163–72. 2 Juvén T, Mertsola J, Waris M, et al. Etiology of community- coinfection. On the other hand, 10% of the acquired pneumonia in 254 hospitalized children. Pediatr children with pneumococcal pneumonia had Infect Dis J 2000;19:293–8. 3 Heiskanen-Kosma T, Korppi M, Jokinen C, et al. Etiology of evidence of M pneumoniae infection. Earlier childhood pneumonia: serologic results of a prospective, aetiological studies have reported evidence of S population-based study. Pediatr Infect Dis J 1998;17:986– 91. pneumoniae and M pneumoniae coinfection in 4 Claesson BA, Trollfors B, Brolin I, et al. Etiology of 29 ambulatory or hospital treated children with community-acquired pneumonia in children based on 3–7 3 antibody responses to bacterial and viral . Pediatr pneumonia. In a recent study, patients with Infect Dis J 1989;8:856–62. the coinfection accounted for 30% of cases of 5 Nohynek H, Eskola J, Laine E, et al. The causes of hospital- treated acute lower respiratory tract infection in children. M pneumoniae infection and for 23% of cases of Am J Dis Child 1991;145:618–22. pneumococcal infection. 6 Ruuskanen O, Nohynek H, Ziegler T, et al. Pneumonia in childhood: etiology and response to antimicrobial therapy. Pneumonia in children may often be caused Eur J Clin Microbiol Infect Dis 1992;11:1–7. by multiple microbial agents.1 Intercurrent or 7 Gendrel D, Raymond J, Moulin F, et al. Etiology and response to antibiotic therapy of community-acquired preceding viral upper respiratory infections are pneumonia in French children. Eur J Clin Microbiol Infect http://adc.bmj.com/ believed to be risk factors for secondary bacte- Dis 1997;16:388–91. 8 Cimolai N, Wensley D, Seear M, Thomas ET. Mycoplasma rial disease. M pneumoniae infection can also pneumoniae as a cofactor in severe respiratory infections. precede viral or other bacterial infections by Clin Infect Dis 1995;21:1182–5. 8 9 9 Staugas R, Martin AJ. Secondary bacterial infections in several days or weeks. Staugas and Martin children with proved Mycoplasma pneumoniae. Thorax reported five cases of M pneumoniae infection 1985;40:546–8. 10 Toikka P, Virkki R, Mertsola J, Ashorn P, Eskola J, with probable secondary infection from H Ruuskanen O. Bacteremic pneumococcal pneumonia in 8 influenzae. Recently, Cimolai and coworkers children. Clin Infect Dis 1999;29:568–72. on September 30, 2021 by guest. Protected copyright.

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