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Refer to: Cherry JD, Welliver RC: Mycoplasma 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 Mycoplasma pneumoniae infection is pneumonia, 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 mycoplasmas 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 Presently, the term confusion related to the spectrum and manage- PPLO has been replaced by Mycoplasma; this is ment of clinical diseases due to mycoplasmas.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 genus of the family Mycoplasmataceae. 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 virus 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 cell wall, 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 penicillin 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- Respiratory tract 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 fever. however, that these isolated cases should be in- Headache 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 Pneumonias 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- Pharyngitis ............. + + + + + + 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 streptococcus 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. Respiratory Disease 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 Bronchitis, bronchiolitis deficiency syndromes'7 and with severe preexist- and croup 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, myalgia Lung 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
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