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Acta Medica Okayama

Volume 56, Issue 2 2002 Article 8 APRIL 2002

A study on intraalveolar exudates in acute mycoplasma pneumoniae infection.

Takeo Yoshinouchi∗ Yuji Ohtsuki† Jiro Fujita‡ Yoshiki Sugiura∗∗ Shogo Banno†† Shigeki Sato‡‡ Ryuzo Ueda§

∗Nagoya City University, †Kochi Medical School, ‡Kagawa Medical University, ∗∗Nagoya City University, ††Nagoya City University, ‡‡Nagoya City University, §Nagoya City University,

Copyright c 1999 OKAYAMA UNIVERSITY MEDICAL SCHOOL. All rights reserved. A study on intraalveolar exudates in acute mycoplasma pneumoniae infection.∗

Takeo Yoshinouchi, Yuji Ohtsuki, Jiro Fujita, Yoshiki Sugiura, Shogo Banno, Shigeki Sato, and Ryuzo Ueda

Abstract

Pathologic features of Mycoplasma pneumoniae infection (M. pneumonia) are generally non- specific, and the literature regarding the pathologic features of M. pneumonia with intraalveolar exudates is limited. Clinical and histopathological studies were performed in 3 patients with M. pneumonia which did not respond to erythromycin and minocycline, but all rapidly recovered after corticosteroid therapy. In pathologic findings, we observed intraalveolar exudates and focal organi- zation in M. pneumonia, and its intraalveolar lesions were compared between M. pneumonia and bronchiolitis obliterans organizing pneumonia containing fibrin (BOOP). Immunohistochemical studies were performed using the streptavidin biotin peroxidase complex method with anti-alpha- smooth muscle actin antibody and anti-pancytokeratin AE1/AE3 antibody. In pathologic findings, more fibrin deposits in intaalveolar lesions were observed in M. pneumonia than in BOOP. In in- taalveolar lesions of M. pneumonia, a larger amount of nuclear debris, more neutrophils, and more erythrocytes were noted. Myofibroblasts were observed in the organization of BOOP, while in the intaalveolar lesions of M. pneumonia, myofibroblasts were not observed. These results suggest that M. pneumonia with intraalveolar exudates responds well to corticosteroid and its intraalveo- lar lesions apparently differed from those in BOOP.

KEYWORDS: exudate, fibrin, Mycoplasma pneumonia, organizing pneumonia, steroid therapy

∗PMID: 12002617 [PubMed - indexed for MEDLINE] Copyright (C) OKAYAMA UNIVERSITY MEDICAL SCHOOL Yoshinouchi et al.: A study on intraalveolar exudates in acute mycoplasma

ActaMed.Okayama,2002 Vol.56,No.2,pp.111-116 Copyrightｃ2002byOkayamaUniversityMedicalSchool.

CaseReport http://www.lib.okayama-u.ac.jp/www/acta/

A StudyonIntraalveolarExudatesin AcuteMycoplasmaPneumoniaeInfection

TakeoYoshinouchi,YujiOhtsuki,JiroFujita，YoshikiSugiura, ShogoBanno,ShigekiSato,andRyuzoUeda

DepartmentofInternalMedicineII,NagoyaCityUniversity,MedicalSchool,Nagoya467-8601,Japan, DepartmentofPathologyII,KochiMedicalSchool,Nankoku783-8505,Japan,and DepartmentofInternalMedicineI,KagawaMedicalUniversity,Kagawa761-0793,Japan

PathologicfeaturesofMycoplasmapneumoniaeinfection (M.pneumonia)aregenerally non- specific,andtheliteratureregardingthepathologicfeaturesofM.pneumoniawithintraalveolar exudatesislimited.Clinicalandhistopathologicalstudieswereperformedin3patientswithM. pneumoniawhichdidnotrespondtoerythromycinandminocycline,butallrapidlyrecoveredafter corticosteroid therapy. In pathologicfindings, weobserved intraalveolarexudatesand focal organizationinM.pneumonia,anditsintraalveolarlesionswerecomparedbetweenM.pneumonia andbronchiolitisobliteransorganizingpneumoniacontainingfibrin(BOOP).Immunohistochemical studieswereperformedusingthestreptavidinbiotinperoxidasecomplexmethodwithanti-α-smooth muscleactinantibodyandanti-pancytokeratinAE1/AE3antibody.Inpathologicfindings,more fibrindepositsinintaalveolarlesionswereobservedinM.pneumoniathaninBOOP.Inintaalveolar lesionsofM.pneumonia,alargeramountofnucleardebris,moreneutrophils,andmoreeryth- rocyteswerenoted.Myofibroblastswereobservedin theorganization ofBOOP,whilein the intaalveolarlesionsofM.pneumonia,myofibroblastswerenotobserved.Theseresultssuggestthat M.pneumoniawithintraalveolarexudatesrespondswelltocorticosteroidanditsintraalveolar lesionsapparentlydieredfrom thoseinBOOP.

Keywords:exudate，fibrin,Mycoplasmapneumonia,organizingpneumonia,steroidtherapy

ycoplasmapneumoniaeinfection(M.pneumonia) limited.RollinsS.reportedthatM.pneumoniashowed M isamilddiseasewithafavorableprognosisasa apolymorpho-nuclearleukocyte-richexudateinthebron- rule,butrecently,severecasesshowingacuterespiratory chiolarluminaandalymphoplasmacyticbronchiolarwall insuciencyhavebeenreported［1,2］.Reporteddata infiltrate［7］.Wereportheretheclinicalfeaturesand suggestthatthepathologicfeaturesofM.pneumoniaare histopathologicalfindingsof3patientswithM.pneumo- notspecificingeneral,andarefrequentlysimilartothose niawhichdidnotrespondtoerythromycinandminocy- ofbronchiolitisorinterstitialpneumonia［3-6］.The cline,butallrapidlyrecoveredaftercorticosteroidther- literatureonthepathologicfeaturesofM pneumoniais apy. Additionally, the pathological findings of intraalveolarlesionswerecomparedbetweenM.pneumo- niaandidiopathicbronchiolitisobliteransorganizingpneu- ReceivedJune18,2001;acceptedSeptember4,2001. moniaassociatingfibrinexudation(BOOP)becausewe Correspondingauthor.Phone:＋81-052-853-8216;Fax:＋81-052-852-0849 observedcharacteristicintraalveolarexudatesandonly

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focalorganizationinM.pneumoniacomparedtothoseof 10.1mg/dl.ChestX-rayrevealedinfiltrativeshadows BOOP. partlyincludingparticulateshadowsintherightupper lungfieldandleftlowerlungfield(Fig.1A).Sputum Methods examinationshowednormalfindings.Coldagglutinintiter was1:128,andMycoplasmaantibodytiter(CF)was1: Lung specimens obtained by transbronchiallung 256(atadmission)and1:1.024(20dayslater).Although biopsy(TBLB)oropenlungbiopsywerefixedin10 erythromycinwasadministeredfor12days,symptoms bueredformalin,thenstainedwithH-E andphos- persisted,andtherewasnochangeininfiltrativeshadows photungsticacid-hematoxylin(PTAH)forfibrin.Im- onchestX-rayfilms.TBLBwasperformedforaccurate munohistochemicalstudiesofdewaxedlungsectionswere diagnosis. Pathologicfindingsofbiopsied specimens performedusingthestreptavidinbiotinperoxidasecom- takenfromtheleftS10revealedanumberofintraalveolar plexmethod(ABC method)accordingtoakitmanual exudateswithmarkedfibrindepositionandfocalorganiza- employinganti-α-smoothmuscleactin(α-SMA)antibody tion,inwhichfibroblasticspindlecellproliferationwas todetectmyofibroblastinintraalveolarspaces(DAKO, observed, containing many erythrocytes, neutrophils, CA,USA,1:200)andanti-pancytokeratinAE1/AE3 andmuchnucleardebris.Inthesurroundinglungfield, antibodytodetectalveolarepithelialcellproliferation markedhyperplasiaofthealveolarepitheliumwasnoted. (Boehringer-Mannheim,Biochemica,Mannheim,Ger- Therapywithoralpredonisone(PSL20mg)wasadminis- many,1:400). tered.Asaresult,subjectivesymptomsdramatically improved,andshadowsonchestX-rayfilmsandcomput- Results edtomographyofthelungs(CT)disappeared(Fig.1B). Case2:A 37-year-oldmalewasadmittedtothe CaseReport.Case1:A44-year-oldmalewasadmit- hospitalbecauseof7dayshistoryofhighfever,cough, tedtothehospitalbecauseof8dayshistoryofhighfever and dyspnea. Physicalexamination demonstrated ta- andcough.Physicalexaminationrevealedtachycardiaand chycardia,hyperpnea,highfever(38.7°C),andfine highfever(38.4°C).Laboratoryfindingsonadmission crackle.Laboratoryfindingsonadmissionwereasfol- wereasfollows:Hb13.2g/dl;whitebloodcell(WBC) lows:Hb13.9g/dl;WBC7,800/μl(neutrophils88 , count,10,300/μl(neutrophils61 ,lymphocytes22 , lymphocytes8 ,eosinophils2 ,monocytes2 ); eosinophils2 ,monocytes12 );erythrocytesedimen- ESR 80mm/h;CRP 6mg/dl;PO54.5 Torr;and tationrate(ESR),77mm/h;C-reactiveprotein(CRP), PCO37.4 Torr. ChestX-ray revealed infiltrative

A B Fig.1 A,achestroentgenogramobtainedonadmissionrevealsinfiltrativeshadowspartlyincludingparticulateshadowsintherightupper andleftlowerlungfieldsofcase1.B,achestroentgenogramaftercorticosteroidtherapyrevealedamarkedimprovementincase1.

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shadowspartlyincludingparticulateshadowsinthebilat- Table1 ComparisonofpathologicalfindingsofbothM.pneumo- erallowerlungfields.Allresultsofatuberculintestand niawithintraalveolarexudatesandBOOP sputumexaminationwerenegative.Mycoplasmaantibody M.pneumonia BOOP titer(CF)was1:128(atadmission)and1:2,048(14days Intraalveolarexudates later).Thepatientwastreatedwitherythromycinand Fibrin ＋＋ ＋～－ flomoxefsodiumfor10days,buthighfeveranddyspnea Nucleardebris ＋ － persistedandinfiltrativeshadowsonchestX-rayfilms Neutrophil ＋ － wereaggravated.Openlungbiopsywascarriedoutfor Redbloodcell ＋ ＋～－ precisediagnosis.Pathologicfindingsoftissuespecimens Plasmacell － ＋～－ Macrophage ＋ ＋～－ takenfromrightS10revealedanumberofintraalveolar Myofibroblast － ＋～－ exudatescontainingfibrindepositionwithfocalorganiza- CoveringbytypeIIepithelium － ＋ tion. Corticosteroid pulsetherapy wasadministered, TypeIIepithelium proliferation ＋＋ ＋ resultingindramaticimprovementofthesubjectivesymp- insurroundings toms,anddisappearanceofshadowsonchestX-raysand CT. Case3:A 28-year-oldfemalewasadmittedtothe pneumoniathaninintraalveolarlesionsofBOOP(Figs. hospitalbecauseof5dayshistoryofhighfeverand 2B,3B).AsshowninFig.3C,withregardtofibro- cough.Physicalexaminationshowedhighfever(38.5°C). blastsintheintraalveolarlesions,stainingwithα-SMA Laboratoryfindingsonadmissionwereasfollows:Hb13 antibody demonstrated proliferation ofmyofibroblasts g/dl;WBC 8,800/μl(neutrophils81 ,lymphocytes positiveforα-SMAantibodyinintraalveolarorganization 15 ,eosinophils1 ,monocytes3 );ESR68mm/h; ofBOOP(Fig.3C),whileinintraalveolarlesionsofM. CRP 6.8mg/dl. Chest X-ray revealed infiltrative pneumonia,myofibroblastswerenotobserved(Fig.2C). shadowsintheleftmiddlelungfield.Mycoplasmaanti- Staining with anti-pancytokeratin AE1/AE3 antibody bodytiter(CF)was1:128(atadmission),and1:512(10 revealedthatthesurfaceoftheintraalveolarorganization dayslater).Thepatientreceivederythromycinfor11 wascoveredwithtypeIIalveolarepithelium inpatients days,buthighfeverpersisted,andinfiltrativeshadows withBOOP,whileinpatientswithM.pneumonia,such onchestX-raysremainedunchanged.TBLBwascarried coveringwasnotnotedatall(Figs.2D,3D).The outforaccuratediagnosis.Pathologicfindingsoftissue resultsdescribedabovearesummarized in Table1. specimenstakenfromtheleftS4revealedthesameasin Intraalveolarlesionsin patientswith M. pneumonia bothcases1and2.Therapywithoralpredonisone(PSL obviouslydieredfromthoseinpatientswithBOOP. 20mg)wasadministered,resultingindramaticimprove- mentofthesubjectivesymptoms,anddisappearanceof Discussion shadowsonchestX-raysandCT. Pathologicalfindings(Table1).Pathologically,all3 M.pneumoniagenerallyrespondswelltoantibiotics patientsexhibitedalmostthesamefindings,revealing anditsprognosisisgood.So,histologicmaterialis commoncharacteristicsofintraalveolarexudateswith rarelyobtainedanditsclassichistologicdescriptionsare focalorganization.Hence,themainpathologicalfindings derived from autopsy. The autopsy lung specimen ofintraalveolarlesions were compared between M. findingsinpreviousreportsareseptalwideningwith pneumoniaandBOOP.H-Estainingshowedmorefibrin plasmacytic,lymphocyticinfiltrates,necrotizingbron- depositsinintraalveolarexudatesofM.pneumoniathan chopneumonias,lymphocyticbronchiolarwallinfiltrates, in intraalveolarlesionsofBOOP. Furthermore, in andbronchiolarluminalcontents［3-6］.In1986,Rollins intraalveolarexudatesofM.pneumonia,moreeryth- S.studiedopenlungbiopsyspecimensfrom 6patients rocytes,neutrophils,andalargeramountofnuclear with M. pneumonia and reviewed the findings debris were also noted (Fig. 2A). In contrast, polymorpho-nuclearleukocyte-richexudatesinthebron- intraalveolarlesionsofBOOP includedafew macro- chiolarlumina,metaplasticcellsthatlinedthebronchioles, phages,lymphocytes,andneutrophils(Fig.3A).Fig. alymphoplasmacyticbronchiolarwallinfiltrate,peribron- 2Band3BillustratePTAH stainingpatterns,showing chiolarseptalwidening,andadjacenthyperplasiaoftype morefibrin depositsin intraalveolarexudatesofM. pneumocytes［7］.Inregardtotheintraalveolarlesions

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Fig. 2 Intraalveolar lesionsinM.pneumonia. A,intraalveolarexudates containalargeamountof fibrin, neutrophils, red blood cells and nuclear debris, associated with alveolartypeIIcellprolif- eration.HEstain×220. B,fibrinwaspositivewith phosphotungstic acid hematoxylin(PTAH)stain. PTAHstain×220. C,bipolarcellswereneg- ative with anti-alpha smoothmuscleactinanti- body.ABCmethod×350. D,intraalveolarexudates werenegativeforpancyto- keratin antibody, AE1/ AE3.ABCmethod×350.

Fig. 3 Intraalveolar lesionsinBOOP. A, intraalveolar lesions mainly consisting of bipolar spindle cells in BOOP.HEstain×220. B, spindle cells in intraalveolarlesionswere concentrically arranged, revealing PTAH-positivity whichsuggestedmyofibro- blasticmaturityinthese spindle cells, butfibrin wasnotdetected.PTAH stain×220. C,bipolarcellswereposi- tive with anti-alpha smoothmuscleactinanti- body.ABCmethod×350. D,alveolartypeIIcells covering intraalveolar organizationwerepositive withantibodytopancyto- keratin AE1/AE3. ABC method×220.

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April2002 IntraalveolarExudateinM.Pneumonia 115

ofM.pneumonia,heindicatederythrocytes,macro- organization［12］.However,patientswithM.pneumo- phages,andneutrophilsbutnotfibrinandnucleardebris. niawithintraalveolarexudatesdidnotdemonstrateany However, detailed pathologicstudiesofintraalveolar proliferationofmyofibroblastsexceptforfewfibroblastic lesionshavenotbeenconducted. spindlecells.InCase2,thesecondTBLBperformed10 InapaperconcerningBOOP ofM.pneumonia, daysafterthefirstlungbiopsyrevealedthealmost Eplerreportedacaseofbronchiolitisobliterans(BO) completedisappearanceoffibrinthathadbeenrecognized associatedwithMycoplasmainfection,inwhichbacterial onthefirstTBLB,butdidnotshow proliferationof infectionhaddeveloped［8］,andCouliasdescribedcases myofibroblastsin intraalveolarlesions. Theseresults ofBO associatedwiththesuspicionofM.pneumonia, suggestthatthehostdefenseagainstMycoplasmainfec- butthediagnosiswasbasedonhighcoldagglutinintiters, tionmaybeweakerinpatientswithM.pneumonia andtherewasnodescriptionofMycoplasmaantibody showingintraalveolarexudatesthaninthosewithBOOP. titers［9］.Then,casesofBO associatedwithM. IninflammatoryprocessesinpatientswithM.pneumonia, pneumoniawerealsoreportedbyPrabhu［10］. In macrophagesarelikelytoplaycentralroles,becausea addition,Mycoplasmaorganizing pneumonia(OP)is number of macrophages are generally present in describedbyLlibreasbronchiolitisobliteransorganizing intraalveolarlesions.AsthepathogenesisofM.pneumo- pneumoniaassociatedwithMycoplasmapneumoniaeinfec- nia, in addition to directdamage by Mycoplasma tion,butdetailedpathologicstudieshavenotbeenreport- pneumoniae,thepossibilityofindirectdamagemediated ed［11］. bytheimmunesystem isalsoconsidered［13,14］. Wereported3patientswithM.pneumoniaexhibiting Therefore, the reason that M. pneumonia with intraalveolarexudateswithfocalorganizationcontaining intraalveolarexudatesrespondedwelltosteroidsbut manyerythrocytes,neutrophils,andmuchnucleardebris. poorlytoantibioticsmaybetheweeknessofthehost ClinicalfeaturesofM.pneumoniadonotdierfrom defenseandtheintensestimulationinthedelayedimmune thoseofgeneralMycoplasmapneumoniaeinfection,but systemaswedescribed.Thismayalsobeareasonthat case 2 was a severe case showing respiratory M.pneumoniawithintraalveolarexudatesshowedpath- insuciency,bearingacloselyparalleltothecasepresent- ologicfeaturesdierentfromthoseofotherkindsofM. edbyLlibreinwhichrespiratoryinsuciencywaspresent pneumoniaand BOOP. In any event, thedistinct aswell. No patientsresponded to erythromycin or dierencesinpathologicfeaturesbetweenM.pneumonia minocycline,butallrapidlyrecoveredaftercorticosteroid withintraalveolarexudatesandBOOPprovideinteresting therapy,andM.pneumoniashowedcharacteristicsof insightsintotheprocessesofintraalveolarorganization. antibiotic-resistanceandsteroid-sensitivity. Mycoplasmainfectionfrequentlydevelopsinyoungpeo- The pathologic features ofM. pneumonia with ple.Hence,cliniciansmustfullyevaluatethepossibility intraalveolarexudateswerecommontoall3patients. ofM. pneumonia with intraalveolarexudates when Namely,pathologiccharacteristicsofM.pneumoniawith patientshavecomplicatingMycoplasmapneumonia.M. intraalveolarexudatesincludedaseveredegreeoffibrin pneumoniawithintraalveolarexudatesdiersfrom M. depositioninintraalveolarexudates,thepresenceofmuch pneumoniawithbronchiolitisandBOOP.Therefore, nucleardebris,manyneutrophils,andmanyerythrocytes whenantibiotic-resistantM.pneumoniawithintraalveolar inintraalveolarexudates,thesurfaceofintraalveolar exudatesissuspected,earlypathologicdiagnosisand exudatespoorlycoveredwithtypeIIalveolarepithelium, corticosteroidtherapyaremandatory. andhighlydevelopedtypeIIalveolarepithelium inthe surroundinglungfield.Toourknowledge,nostudies References haveinvestigatedpathologicfeaturesofM.pneumonia withintraalveolarexudatesindetail.AsshowninTable 1. ChanEDandWelshCH:FulminantMycoplasmapneumoniaepneumo- nia.WestJMed(1995) ,133-142. 1,theseobservationsseemtoindicatethatmoreintense 2. MarrieTJ,PeelingRW,FineMJ,SingerDE,ColeyCMandKapoor stimulationwasindusedinthebodyinpatientswithM. WN:Ambulatorypatientswithcommunity-acquiredpneumonia:The pneumoniathaninpatientswithBOOP.Inpatientswith frequencyofatypicalagentsandclinicalcourse.AmJMed(1996) , BOOP as well, fibrin was sometimes found in 508-515. 3. KoletskyRJandWeinsteinAJ:FulminantMycoplasmapneumoniae: intraalveolar lesions, but on such occasions, Reportoffatalcase,andareviewoftheliterature.AmRevRespirDis myofibroblastsgrewwithabsorptionoffibrin,promoting (1980) ,491-496.

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4. GoldenA:Pathologicanatomyof‘atypicalpneumonia,etiologyun- 10. PrabhuMB,BarberDandCockcroftDW:Bronchiolitisobliteransand determined’:Acuteinterstitialpneumonitis.ArchPatholLabMed Mycoplasmapneumonia.RespirMed(1991) ,535-537. (1994) ,187-202. 11. LlibreJM,UrbanA,GarciaE,CarrascoMAandMurciaC:Bron- 5. LevineDPandLernerAM:Theclinicalspectrum ofMycoplasma chiolitisobliteransorganizingpneumoniaassociatedwithacuteMyco- pneumoniaeinfections.MedClinNorthAm(1978) ,961-978. plasmapneumoniaeinfection.ClinInfectDis(1997) ,1340-1342. 6. EmbreeJEandEmbilJA:Mycoplasmasindiseasesofhumans.Can 12. YoshinouchiT,OhtsukiY,KuboKandShikataY:Clinicopathological MedAssocJ(1980) ,105-111. studyontwotypesofcryptogenicorganizingpneumonitis.RespirMed 7. RollinsS,ColbyTandClaytonF:OpenlungbiopsyinMycoplasma (1995) ,271-278. pneumoniaepneumonia.ArchPatholLabMed(1986) ,34-41. 13. StuartPM:Mycoplasmalinductionofcytokineproductionandmajor 8. EplerGR,ColbyTV,McloudTC,CarringtonCBandGaenslerEA: histocompatibilitycomplexexpression. Clin InfectDis(1993) , Bronchiolitisobriteransorganizingpneumonia.NEnglJMed(1985) S187-S191. ,152-158. 14. RazinSandFreundtEA:TheMycoplasmas;inBergeysManualof 9. CoultasDB,SametJMandButlerC:Bronchiolitisobliteransdueto SystematicBacteriology,KriegNRandHoltJGeds,Williamaand Mycoplasmapneumoniae.WestJMed(1986) ,471-474. Wilkins,Baltimore(1984)pp766-767.

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