Refer to: Cherry JD, Welliver RC: pneumoniae in- fections of adults and children (Medical Progress). Medical West J Med 125:47-55, Jul 1976 PROGRESS

Mycoplasma Pneumoniae Infections of Adults and Children JAMES D. CHERRY, MD, and ROBERT C. WELLIVER, MD, Los Angeles

Although the hallmark of infection is , the organism is also responsible for a protean array of other symptoms. With an increased awareness of the broad clinical spectrum of M. pneumoniae disease and the ready availability of the cold agglutinin and M. pneumoniae complement-fixation tests, interested clinicians will note additional clinical- mycoplasmal associations in their patients.

MYCOPLASMA PNEUMONIAE INFECTIONS are re- this, numerous other were isolated sponsible for a considerable number of human from cattle and other animals.' These other my- illnesses. Although there is a vast amount of coplasmas were originally called pleuropneumo- scientific knowledge available, there is still much nia-like organisms (PPLO). Presently, the term confusion related to the spectrum and manage- PPLO has been replaced by Mycoplasma; this is ment of clinical diseases due to mycoplasmas. one of the family . My- The purpose of this article is to review M. pneu- coplasmas have been isolated from many different moniae infections of children and adults in a way animals including man. M. pneumoniae, initially that will be useful to clinicians. Particular atten- called the Eaton agent, was identified in associa- tion will be given to the less well-known mani- tion with primary atypical pneumonia in 1944.4 festations of M. pneumoniae infections. The Eaton agent was originally believed to be a until Marmion and Goodburn5 in 1961 Definition and History showed that it was identical to pleuropneumonia- Mycoplasmas are the smallest free-living micro- like organisms. During the same year, Chanock organisms; they lack a , they grow on and colleagues6 administered a tissue culture lifeless media but require sterol for growth, and grown Eaton agent strain to human volunteers they are resistant to but sensitive to and produced respiratory illness similar to pri- several other antibiotics." 2 Nocard and Roux3 mary atypical pneumonia. Although several dif- isolated the first mycoplasma species (now known ferent mycoplasmas have been recovered from as M. mycoides var mycoides) from cattle with humans (Table 1), the present report is only con- contagious pleuropneumonia in 1898. Following cerned with M. pneumoniae infections. It is to out at the onset that From the Department of Pediatrics, Division of Infectious Dis- important point eases, University of California, Los Angeles, Center for the Health in this report many of the clinical manifestations Sciences. Reprint requests to: James D. Cherry, MD, Department of commented on were sporadic events and therefore Pediatrics, Division of Infectious Diseases, UCLA School of Medicine, Los Angeles, CA 90024. may not necessarily have had a cause and effect

THE WESTERN JOURNAL OF MEDICINE 47 MYCOPLASMA PNEUMONIAE INFECTIONS TABLE 1.-Mycoplasmas* Recovered from Humans7 The incidence of pneumonia due to M. pneu- Genital tract moniae is greatest in persons between the ages of M. pneumoniae M. hominis 5 and 15 years while the percentage of all pneu- M. orale (three types) M. fermentans monia attributable to M. pneumoniae is highest M. salivarium "T" - strains in late teenage and early adult years, when pneu- *Listed by site of most common recovery. monia due to all other causes is less com- mon. -10,12 Pneumonia due to M. pneumoniae is relationship with M. pneumoniae infection. There uncommon in persons less than 4 or greater than is always the possibility of dual infection with the 60 years of age.9"10 unrecovered infectious agent being responsible Symptoms and Signs.9-14 Illness usually presents for the symptoms. It is the opinion of the authors, with the gradual onset of malaise and . however, that these isolated cases should be in- may also be a predominant early cluded, with reservation, as they offer valuable symptom. Cough begins after three to five days points of reference for the observers. (See Figure and becomes increasingly prominent. Initially 1 for clinical associations.) nonproductive, the cough may later produce frothy, white or even blood-tinged sputum. Find- Clinical Disease ings on Gram stain of the sputum show polymor- Pneumonia phonuclear leukocytes with no predominant Incidence. The incidence of pneumonia due to bacterial type evident. Gastrointestinal symptoms M. pneumoniae in the general population is ap- of anorexia, nausea and abdominal pain may proximately one case per 1,000 persons per year. occur. A pertussis-like syndrome with paroxysms During epidemic periods, rates as high as three of coughing has been described.'5 per 1,000 have been noted.8 M. pneumoniae in- Temperatures from 1000 to 103°F (37.80 to fections account for about 10 to 20 percent of 39.4°C) are common while higher temperatures all cases of pneumonia.9-11 Since isolation rates are unusual.'9 Physical findings are generally of do not vary greatly during the year, M. pneumo- little aid in distinguishing M. pneumoniae pneu- niae causes a greater proportion of pneumonia monia from that of other causes. However, as during the summer months when pneumonia due noted in Table 2, coryza is less common and to other organisms is less common.9"2 lymphadenopathy more apparent in persons with

Figure 1.-Clinical associa- tions of Mycoplasma pneu- moniae.

48 JULY 1976 * 125 * 1 MYCOPLASMA PNEUMONIAE INFECTIONS TABLE 2.-Relative Frequency of Selected Symptoms usually normal.8'1 However, Turner and col- and Signs in Patients with Mycoplasma pneumoniae Pneumonia and Patients with of other leagues noted that the total leukocyte count was Typesl' greater than 10,000 cells per cu mm in 13 of 22 M. Pneumoniae Pneumonias of children with M. pneumoniae infections; in 15 Findings Pneumonia Other Types children, the differential percentage showed Cough ...... ++++ ++++ greater than 60 percent polymorphonuclear cells. Headache ...... +++ +++ The sedimentation rate is frequently quite ele- ...... + + + + + + Sputum ...... + + + + + + vated.25 Serologic tests for syphilis are occasion- Lymphadenopathy ...... + ++ + + ally noted to be falsely positive, serum cold Conjunctivitis ...... + + + + agglutinins are frequently observed and antibodies Temperature >40°C . .... ++ ++ Coryza ...... ++ + + + to MG antigen are found.6"0283' Pleuritis ...... + + Serum IgM is frequently elevated while levels of IgG and IgA are normal.30 The direct Coombs' M. pneumoniae pneumonia than in patients with test occasionally gives positive findings.30 pneumonias of other causes. other than Pneumonia Dry rales are the most common finding on aus- cultation of the chest. for four General. M. pneumoniae infections account for They may persist a significant amount of respiratory illness other weeks or more even though the patient is clini- than 1013'20'31-35 cally improved. Symptoms of consolidation and pneumonia. Between 0 and 8 per- friction rub may occur, substernal pain may be cent of all upper respiratory infections are due to present but pleuritic pain is uncommon. M. pneumoniae. Pharyngitis is not uncommonly associated with M. pneumoniae infection; the M. pneumoniae pneumonia is more severe in peak incidence of M. pneumoniae pharyngitis is patients with sickle cell anemia,'6 with immuno- at 12 to 14 years old.32 , deficiency syndromes'7 and with severe preexist- and have all been noted in association ing cardiorespiratory problems.'8" 9 Although rare with M. pneumoniae infection.'0"13'33-35 Symptoms deaths have occurred, recovery is usual, although in these illnesses of children are usually mild. the clinical course is variable if untreated. Cough In adults, exacerbations of chronic obstructive persists for three to four weeks in adults and pulmonary disease have been associated with M. usually for a shorter time in children,8"0 while pneumoniae infections.36'37 nonrespiratory symptoms of headache, Abscess. Three patients with lung ab- and malaise may remit 7 to 10 days after their scess in association with M. pneumoniae infection onset. have been reported.38'39 All three patients were Roentgenography. Inconsistent relationships males, aged 17, 24 and 45 years. All had two to among the degree of symptoms, physical findings four week histories of productive cough and and results of chest roentgenographs are a hall- pleuritic chest pain. In one patient, who was mark of mycoplasma infection.9'10' 4"15'20 In many treated with tetracycline, there was dramatic im- persons in whom significant infiltrates are seen on provement and on a follow-up roentgenograph chest roentgenographs, there are no or minimal six weeks later only minimal lingual scarring was pulmonary findings. The radiologic pattern of M. seen. In the other two patients there was transient pneumoniae pneumonia cannot be distinguished relief of symptoms during a week of therapy with from other nonbacterial pneumonias.2' Early in tetracycline, but relapse occurred when the medi- the course of M. pneumoniae pneumonia, the pat- cation was discontinued. Both of these two pa- tern is reticular and interstitial; subsequently, tients eventually recovered although in neither small patchy areas of superimposed consolidation was optimal antibiotic therapy carried out. are noted. Lower lobe involvement is most com- In a review of chest roentgenograms of 180 mon and radiating infiltrates from the hilum are patients with pneumonia thought to be due to a frequent finding. Occasionally, lobar involve- M. pneumoniae, four cases were found in which ment is noted and also occurs.22'23 pneumatoceles were present, all clearing eventu- In untreated patients, roentgenographic findings ally.21 may persist for a month or longer.24 Otitis Media. Both acute otis media and the Routine Laboratory Data. The total leukocyte less common bullous hemorrhagic myringitis count in pneumonia due to M. pneumoniae is have been observed in M. pneumoniae infec-

THE WESTERN JOURNAL OF MEDICINE 49 MYCOPLASMA PNEUMONIAE INFECTIONS tions.9, 10,20,33,35,40-42 In volunteer studies with tissue of hemolysis may be the rapid agglutination of culture grown M. pneumoniae, Rifkind and asso- blood in the syringe used for venipuncture.47 ciates40 noted that in 13 of 52 subjects myringitis Examination of a blood smear shows red cell ag- developed. Interestingly, myringitis occurred in glutination, moderate spherocytosis, presence of 12 of 27 men without preinoculation of M. pneu- polychromatic cells and at times erythrophagocy- moniae antibody and in only one subject with pre- tosis.46-48 The serum bilirubin is usually between inoculation antibody. The myringitis had an incu- 1 and 3 mg per 100 ml. The leukocyte count may bation period of six to nine days, was usually be elevated to a pronounced degree with a pre- bilateral and was associated with throbbing pain. dominance of neutrophils, thereby confusing the The appearance of the eardrum varied from mild diagnosis of M. pneumoniae infection. The direct infection to severe inflammation with edema. In Coombs test usually gives positive findings.30'46-48 five patients, hemorrhagic areas were noted and Pathogenesis. The pathogenesis of acute hemo- in two of these subjects serous-filled blebs which lytic anemia in M. pneumoniae infection is un- later contained blood were noted. Bullous my- clear. In vitro, M. pneumoniae liberates peroxide ringitis has also been noted in several occasions which is a vigorous hemolysin.31 However, in an with natural M. pneumoniae infections.9 20'33'42 organ culture system that is more akin to in vivo The significance of M. pneumoniae infection in conditions, excessive peroxide liberation could the etiology of common acute otitis media in not be shown.50 Since the occurrence of hemo- children is unclear. In a study of 106 children lytic anemia has only been noted in association with acute otitis media, Halsted and colleagues4' with notably elevated cold-agglutinin titers, it were unable to recover M. pneumoniae from would seem that autoimmunity is of importance middle ear fluid. However, in 12 percent of the on pathogenesis. It would seem reasonable to children there was serologic evidence of M. pneu- suggest that mycoplasma organisms cause a tem- moniae infection. Jensen and associates35 noted porary alteration of red blood cell membranes laboratory evidence of M. pneumoniae infection so that an autoantibody response occurs. In the in 47 of 79 children with otitis media. In this in- patient studied by Fiala and co-workers,45 bone vestigation, study children were selected because marrow suppression also contributed to the of suspected M. pneumoniae infection in a family anemia. member. Prognosis. Hemolytic episodes are usually brief . Acute sinusitis is not an uncommon and self-limited, but have resulted in renal failure complication of a variety of acute infectious res- and death.48 A beneficial effect of prednisone ad- piratory illnesses. However, clinically recogniz- ministration has been suggested but not ade- able sinusitis was infrequently noted in persons quately evaluated.46 Since cold-agglutination may with M. pneumoniae pneumonia.29 However, play a role in pathogenesis, it would seem wise when a radiographic search for evidence of sinus- to warm blood for transfusion to body tempera- itis was made in 80 persons with M. pneumoniae ture in patients with suspected M. pneumoniae infection, two thirds had sinusitis.43 In these cases, infections. the presence of sinusitis significantly prolonged the illness. In 30 patients with chronic suppura- Central Nervous System Disease tive maxillary sinusitis, Sprinkle44 was unable to Clinical. A surprising spectrum of acute neuro- isolate mycoplasmas from antral lavage speci- logic illness has been associated with M. pneu- mens. moniae infection.'0' 11,15,18,28,34,48,51,52 The frequency of specific types of clinical involvement in 50 Hemolytic Anemia cases reviewed by Lerer and Kalavsky5' is pre- Clinical. Hemolytic anemia associated with M. sented in Table 3. Combination involvement oc- pneumoniae infection has been reported on sev- curred in 36 percent of the cases. In 79 percent eral occasions, but its occurrence is uncom- of the patients there was a history of antecedent mon.'1030'31'45-49 Hemolysis may be severe with a respiratory illness. Neurologic illness occurred 50 percent reduction in hemoglobin occurring from 3 to 23 days after the onset of respiratory acutely. Severity correlates with high titers of illness; the average interval was 10 days. The cold agglutinins. A clinically inapparent, com- youngest patient was 6 years old and 47 percent pensated hemolysis may also occur.30 were less than 20 years old. Of the patients less Laboratory. In severe cases, the first evidence than 20 years old, 77 percent were males.

50 JULY 1976 * 125 * 1 MYCOPLASMA PNEUMONIAE INFECTIONS TABLE 3.-The Frequency of Specific Clinical Involve- them most commonly had its onset during the ment in 50 Patients with Neurologic Disease Associated with Mycoplasma pneumoniae Infection5l febrile period. Enanthem occurred in 15 persons and it was Frequency Clinical Involvement (Percent) severe in 10. In four patients severe conjunctivitis Generalized encephalitis ...... 30 was present. Severe conjunctivitis only occurred in Spinal nerve roots ...... 30 persons in whom there were vesicular or bullous Meningitis ...... 20 exanthems, and in all four patients with severe Cranial nerves ...... 20 eye involvement, generalized ulcerative stomatitis Focal encephalitis ...... 16 Cerebellum ...... 14 also was present. Interestingly, vesicular or bul- Psychosis ...... 8 lous exanthems were not noted in females nor was Spinal cord ...... 2 ulcerative stomatitis or severe conjunctivitis. In most patients, the spectrum of other symp- Five patients were older than 50 years of age. toms was similar to those in patients with M. This surprising number of cases in an age group pneumoniae infections without exanthem. Only in which M. pneumoniae infections are unusual two of the 20 cases analyzed did not have pneu- would suggest a greater relative incidence of monia. The occurrence of an isolated rash as the neurologic disease in older persons. single manifestation of M. pneumoniae infection Prognosis. Five deaths have been noted, and is probably rare. In a study of 112 patients with major complications unrelated to the nervous sys- suspected acute infectious exanthems, no signifi- tem had played a significant role in all (for ex- cant antibody titers to M. pneumoniae were ample, pulmonary embolus, pneumonia, sepsis). 51 noted.57 In other patients there has been residual evidence Pathogenesis. The pathogenesis of exanthem in of neurologic damage, mostly weakness but in- M. pneumoniae infection is unknown. In many cluding hemiparesis, paraplegia and aphasia. Re- patients, the enanthem-exanthem complex is con- sidua occurred more frequently in patients sistent with the Stevens-Johnson syndrome. These younger than 14 years of age who presented with findings might suggest an autoimmune phenomena focal encephalitis or radiculitis. There is no ap- perhaps with events similar to those inducing parent correlation between severity of neurologic hemolytic anemia. It is important to point out, disease and height of cold-agglutinin or M. pneu- however, that in two instances M. pneumoniae moniae complement-fixation antibody titers. has been recovered from blister fluid of patients with erythema multiforme;58 in these cases, the Exanthem and Enanthem exanthem could result from a direct effect of the Incidence. Exanthem in association with M. infectious agent. pneumoniae infection is more common than Many of the patients with M. pneumoniae in- generally appreciated.53'54 In a five year study in fection and exanthem have received antibiotics Seattle, 17 percent of 319 persons with M. pneu- before the onset of the rash. Therefore, the pos- moniae penumonia had exanthem.9 Copps and sibility of a drug eruption must be considered. In colleagues55 noted that 11 percent of children the analysis of the 20 detailed cases,53 12 patients with M. pneumoniae infections in a community had received antibiotics before exanthems oc- outbreak in La Crosse, Wisconsin had exanthem curred but six patients had a definite history of and Feizi and co-workers56 noted rash in a third exanthem before antibiotic therapy. Although it of 40 patients in an outbreak in Scotland. is obvious that antibiotics cannot be incriminated Clinical Findings. In a recent review, 20 well- in all cases, it is possible that M. pneumoniae in- documented cases of exanthem with M. pneu- fection intensifies the dermosensitive potential of moniae were analyzed.53 All but four of the pa- certain antibiotics in a manner similar to that tients were males and 19 of the 20 cases occurred noted between the Epstein-Barr virus and ampi- in persons 4 to 20 years of age. Selected clinical cillin in infectious mononucleosis. findings are presented in Table 4. Skin manifesta- tions were varied although in nine persons there Arthritis were vesicular or bullous lesions, or both. Pruritis Mycoplasmas are a common cause of arthritis was noted in five patients. The duration of the in animals other than man.59 Eleven types of my- rash was approximately seven days in all but one coplasmas have been clearly implicated in ar- patient. All patients were febrile and the exan- thritides of seven different animals. Because many

THE WESTERN JOURNAL OF MEDICINE 51 MYCOPLASMA PNEUMONIAE INFECTIONS TABLE 4.-Major Clinical Findings in 20 Patients with thralgia. In contrast, only 9 percent of persons Mycoplasma pneumoniae Infection and Exanthem53 with adenovirus pneumonia had similar com- Number of Clinical Category Patients plaints. Distinguishing characteristics of exanthem Cardiac Disease Vesicular and/or bullous ...... 9 Maculopapular ...... 6 Cardiac involvement during M. pneumoniae Macular ...... 2 infection is unusual. In a series of 300 cases of Papular ...... 1 Urticarial ...... 1 M. pneumoniae infection, Hers49 noted one pa- Petechial ...... 1 tient with myocarditis. Grayston and colleagues14 Duration of exanthem noted one 20-year-old girl with transient <7 days ...... 1 peri- 7 to 14 days ...... 10 carditis in a study of 69 proven M. pneumoniae > 14 days ...... 5 cases. A recent case report describes a 71-year- Not specified ...... 4 old man with the Enanthem acute onset of an illness sug- Generalized ulcerative stomatitis ...... 10 gestive of . At autopsy, effusions or pharyngitis ...... 5 were found in the pericardial sac, pleural space, Conjunctivitis subdiaphragmatic area and in both knee joints. Severe ...... 4 Mild ...... 3 Mycocarditis and mitral valve lesions without Pneumonia Aschoff bodies were found. There was no labora- Yes ..... 18 tory or histologic evidence to indicate strepto- No. 2 coccal infection, but pure cultures of M. pneu- moniae were obtained from blood and from the of the diseases in animals are suggestive of hu- pericardial effusion.63 man rheumatoid arthritis considerable search for mycoplasmas in human arthritides has been done. Lambert15 reported the case of a 50-year-old man who had acute pericarditis. This patient's At present, several mycoplasmas other than M. initial illness pneumoniae have been noted in association with required a three week stay in hos- rheumatoid arthritis. However, the results of pital; three months later, the patient experienced a second attack. studies to date are controversial and raise more than answer. questions they Pancreatitis Although it is highly unlikely that M. pneu- moniae has a role in the cause of rheumatoid Mardh and Ursing65 reported six instances of arthritis, joint manifestations have been noted pancreatitis in patients with pneumonia due to during infections with this agent.15 26'60-67 In five M. pneumoniae. Two of the patients had only reports60-64 ten instances of illnesses resembling vague symptoms of pancreatitis but increased rheumatic fever and associated with M. pneu- concentrations of serum amylase were noted. moniae infections have been described. Seven of In three of the other four patients, the pancreatic the ten patients were males. One patient was symptoms began one to two weeks after the onset three years old, six were adolescents and three of respiratory illness; in one patient respiratory were adults. Most of the patients had a history and pancreatic symptoms were concurrent. Dia- of preceding respiratory illness including sore betes mellitus developed in two patients and one throat. When tested, sedimentation rates were of them died in a hyperosmolar, nonketotic, hy- found to be elevated. Seven patients had arthritis perglycemic coma. with swelling or effusion, and three had only Leinikki and Pantzer66 noted four-fold rises in joint pain. The knees were involved in all ten complement fixation antibody titer to M. pneu- patients. In seven of the ten patients there was moniae in 18 of 56 patients with pancreatitis. roentgenographic evidence of pneumonia. None of these patients had pneumonia. Since the One of the ten patients, a 71-year-old man, illnesses in these patients were so different from died with pericarditis and pneumonia. In the other other M. pneumoniae infections, the authors sug- patients, recovery was complete but after a pro- gested that perhaps a different but antigenically- longed period. related mycoplasm was the cause. Alternatively, In 175 patients with M. pneumoniae pneu- they also raised the possibility of a false positive monia, George and co-workers26 noted that 20 complement fixation test due to auto-antibodies percent complained of myalgia, backache or ar- to necrotic pancreatic tissue.

52 JULY 1976 * 125 * 1 MYCOPLASMA PNEUMONIAE INFECTIONS Communicability of M. Pneumoniae Infections Complement-Fixation Antibody Titers The rate of infection with M. pneumoniae is Although there are several specific tests that high in areas of close personal contact, such as can be used to measure antibodies to M. pneu- families 20'34'35'67'70 armed service camps68'69 and moniae, the complement-fixation test is the only fraternities.71 In family studies, the attack rates test readily available for routine laboratory use.'0 vary between 64 and 71 percent among chil- This test employs commercially available antigen dren and between 17 and 53 percent among and the results are satisfactory for usual diag- adults.20'67'70 In 74 percent of new Marine recruits ostic purposes. four-fold antibody titer rises to M. pneumoniae developed during their 10 to 16 week training A four-fold rise in complement-fixation anti- period.'8 body titer is indicative of M. pneumoniae infec- In contrast with families and military recruit tion. Mycoplasma complement-fixing antibodies in schools remain elevated for considerable periods so ele- training groups, the communicability value in disease is low.70 It is more usual for school children to vated single titers are of little become infected by neighborhood playmates than diagnosis.74 It is important to point out, how- general classroom exposure. ever, that four-fold rises in antibody titer can The incubation period of M. pneumoniae in- occur in very short time periods. A second speci- fection is about three weeks.67'70 Community epi- men collected within a week of the acute-phase demics due to M. pneumoniae are frequently serum will frequently show a four-fold titer rise. protracted. Even in families, slow spread of the infectious agent is common and household in- Culture volvement may continue for two months. Infec- With proper media and technique, M. pneu- tion is most commonly spread by children of moniae is readily isolated from throat swabs of school age and by those patients who have a infected patients. However, M. pneumoniae is a cough.10'67'71 relatively slow growing mycoplasma and there- Tests fore its isolation is of little use clinically. Serologic Diagnostic Laboratory diagnosis is more practical. Serum Cold Agglutinins The determination of serum cold agglutinins in Therapy patients suspected of M. pneumoniae infections is a simple and useful procedure. In pneumonias The therapeutic effectiveness of demethychlor- due to M. pneumoniae infections, cold agglu- tetracycline in pneumonia due to M. pneumoniae tinins at a titer of approximately 1:32 will be was clearly shown in 1961 by Kingston and co- present about 75 percent of the time.253' Con- workers.24 Since that time, several other antibi- versely, in patients with pneumonia and positive otics have been carefully studied and also found cold agglutinins, a specific antibody to M. pneu- to be effective.9" 0'75 In vitro data indicate that M. moniae will develop in 72 to 92 percent. In gen- pneumoniae strains are exquisitely sensitive to eral, the cold agglutinin response correlates di- erythromycin, tetracycline, oxytetracycline and rectly with the severity of illness. demethylchlortetracycline.'0 When expense and Cold agglutinins have also been observed in possible adverse drug reactions are considered, it 18 percent of adenovirus pneumonias in air force would seem that the drugs of choice in M. pneu- recruits26 and in a variety of nonmycoplasmal moniae infections are either erythromycin respiratory illnesses of young children.72 In gen- stearate or tetracycline hydrochloride.9"075 Be- eral, the higher the cold agglutinin titer the more cause of the adverse effect of tetracycline of den- likely a specific infection is due to M. pneumoniae tition,76 erythromycin is the drug of choice in infection. children. A rapid screening test for cold agglutinins can Despite the clinical effectiveness of antibiotics, be done by an interested clinician.73 In this test, organisms may still be recovered from throat cul- four drops of blood are collected in a tube con- tures during and after therapy.20'35 In the family taining 0.2 ml of 3.8 percent sodium citrate solu- situation, Jensen and colleagues35 noted that the tion. The tube is placed in ice water (0 to 4°C) prophylactic use of oxytetracycline did not pre- for one-half minute and then examined for coarse vent infection of contacts but did render most agglutination by tilting the tube on its side. infections asymptomatic.

THE WESTERN JOURNAL OF MEDICINE 53 MYCOPLASMA PNEUMONIAE INFECTIONS

25. Jansson E, Von Essen R, Tuuri S: Mycoplasma pneumoniae Prevention in Helsinki 1962-1970: Epidemic pattern and autoimmune mani- festations. Scand J Infect Dis 3:51, 1971 Inactivated M. pneumoniae vaccines have been 26. George RB, Ziskino MM, Rasch JR, et al: Mycoplasma tried with variable results. Mogabgab77 re- and adenovirus pneumonias. Ann lntern Med 65:931, 1966 27. Turner JAP, Burchak EC, Bannatyne RM, et al: The pro- ported significant protection following vaccina- tean manifestations of Mycoplasma infections in childhood. Can Med Assoc J 99:633, 1968 tion, whereas Smith and associates78 noted that 28. Biberfeld G: Antibodies to brain and other tissues in cases of Mycoplasma pneuimoniae infection. Clin Exp Immunol 8:319, some vaccine recipients appeared to have more 1971 29. Griffin JP, Crawford YE: Mycoplasma pneuioniae in pri- severe disease upon later exposure to M. pneu- mary atypical pneulmonia. JAMA 193:1011, 1965 moniae. A recent trial with a live temperature 30. Feizi T: Cold agglutinins, the direct Coombs' test, and serum inimunoglobulins in Mycoplasmna ptnentmoniae infections. sensitive mutant of M. pneumoniae gave en- Ann NY Acad Sci 143:801, 1967 31. Chanock RM: Mycoplasma infections of man. N Engl J couraging results.79 The mutant was avirulent in Med 273:1199, 1965 volunteers but appeared to stimulate resistance 32. Glezen WP, Clyde WA, Senior RS, et al: Group A Strep- tococci, Mycoplasmas, and associated with acuLte pharyn- to subsequent challenge. gitis. JAMA 202:455, 1967 33. Clyde WA, Denny FW: Mycoplasma infections in child- hood. Pediatrics 40:669, 1967 REFERENCES 34. Balassanian N, Robbins FC: Mycoplasma pneumitoniae in- fection in families. N Engl J Med 277:719, 1967 1. Hayflick L: Fundamental biology of the class , order Mycoplasmatales, In Hayflick L (Ed): The Mycoplasmatales 35. Jensen KJ, Senterfit LB, Scully WE, et al: Mycoplasmna and the L-phase of . 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Folk Remedies

Because of the number of Vietnamese people in the West, the use of folk remedies for illnesses may occasionally present unique diagnostic findings and should be recognized by practicing physicians. A 2½/2-year-old Vietnamese girl presented to the Emergency Room at Childrens Hospital of Los Angeles with a three to four day history of fever, cough and . Positive physical find- ings included boggy erythematous nasal turbinates, mild erythema of the and a confluent petechial rash in the infraclavicular area of the chest bilaterally. A complete blood count showed a leukocyte count of 11,000 per cu mm with 60 percent lymphocytes and platelets within normal limits. Several other Vietnamese children have been treated in our emergency room with similar rashes in the paraspinal and subscapular areas. Histories showed that these lesions are directly due to the popular practice among the Vietnamese population of using a coin to rub a mentholated compound vigorously into the skin in the infraclavicular, paraspinal and subscapular areas for approximately five minutes. The indications for this treatment include fever, rhinorrhea, cough and nonspecific symptoms in patients of all ages. Although less prevalent, coin massage with mentholated compounds may be used over the area of the biceps to treat abdominal pain. The use of hyperthermia applied with a coin and mentholated compounds plays a major role in Vietnamese folk medicine and its external manifestations should be recognized. EUGENE KELLER, MD Emergency Serv-ices, Childrens Hospital of Los Angeles JOHN B. BLAIR, MD Emergency Resident, Los Angeles County/University of Southern California Medical Center

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