Cases reported • Pneumonia, Mycoplasma; Mycoplasma Pneumonia; Pneumonia, Primary Atypical

1/10. Severe hemolytic anemia and excessive leukocytosis masking mycoplasma pneumonia.

The formation of cold agglutinins is frequently observed during mycoplasma pneumoniae infections. Nevertheless, severe hemolysis is exceptional. We report a case of life-threatening hemolytic anemia caused by M. pneumoniae. As the leucocyte count was excessively elevated, the differential diagnosis primarily comprised hematological malignancies. The presence of cold agglutinins indicated the correct diagnosis, which was confirmed by highly elevated levels of both IgG and IgM antibodies to M. pneumoniae and a chest X-ray suggestive of atypical pneumonia. The patient was treated with roxithromycin and showed a favorable recovery within ten days after admission. This case demonstrates that, even in patients with clinically mild pneumonia, M. pneumoniae may be the cause of severe anemia.

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2/10. Amniotic membrane in the surgical management of acute toxic epidermal necrolysis.

OBJECTIVE: To report a new surgical technique to manage severe acute toxic epidermal necrolysis. DESIGN: Two interventional case reports. PARTICIPANTS: Two patients. Case 1: A 6-year-old boy had severe toxic epidermal necrolysis develop after being treated with trimethoprim and sulfamethoxazole for chronic otitis media. Both eyes and eyelids were affected. He underwent bilateral lysis of symblepharon and all adhesions and bilateral amniotic membrane transplantation to the entire ocular surface except the cornea. Loss of eyelid skin required transplantation of amniotic membrane to all four eyelids and strips of amniotic membrane at the eyelid margins. Case 2: An 8-year-old girl with severe toxic epidermal necrolysis associated with mycoplasma pneumonia had bilateral, diffuse keratoconjunctivitis, diffuse corneal epithelial defects, and bilateral symblepharon. Amniotic membrane transplantation was performed bilaterally, using a symblepharon ring in the left eye. INTERVENTION: Amniotic membrane transplantation. MAIN OUTCOME MEASURES: Preservation of normal ocular and eyelid surfaces and prevention of blindness. RESULTS: Case 1: Thirty-six months after bilateral ocular surgery, there is no symblepharon, good ocular surface wetting, and an uncorrected bilateral vision of 20/20. Case 2: Amniotic membrane transplantation protected both ocular surfaces and prevented conjunctival contracture without adhesion of the eyelids to the ocular surface. The central vision was preserved. There was minimal peripheral corneal vascularization and mild conjunctival scarring of the tarsal conjunctival surface 34 months postoperatively. CONCLUSIONS: These are the first cases of acute toxic epidermal necrolysis treated with amniotic membrane transplantation and the first use of the procedure on external eyelid surfaces with good healing of the eyelids. This new treatment for acute toxic epidermal necrolysis preserves normal ocular and eyelid surfaces and may prevent blindness.

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3/10. stevens-johnson syndrome: a diagnostic challenge in the absence of skin lesions.

We report a 14-year-old boy with stevens-johnson syndrome who presented with mucous membrane lesions but without skin lesions and discuss the differential diagnosis of oral mucous membrane lesions in childhood. stevens-johnson syndrome in children is most frequently caused by a mycoplasma pneumoniae infection. The full clinical picture of stevens-johnson syndrome can be present before seroconversion of Mycoplasma antibodies is observed. One should keep in mind that one negative titer of Mycoplasma antibodies does not rule out M. pneumoniae infection.

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4/10. adult respiratory distress syndrome associated with mycoplasma pneumoniae infection.

A 13-year-old boy is described who developed severe adult respiratory distress syndrome (ARDS), biochemical pancreatitis and skin vasculitis after an acute respiratory infection due to mycoplasma pneumoniae. The boy was mechanically ventilated for 17 days, but could be discharged in good clinical condition after 36 days of hospitalization. However, major disturbances of the lung function tests persisted, suggesting interstitial fibrosis. To the best of our knowledge, this is the first case of ARDS after M. pneumoniae infection in childhood.

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5/10. cold haemagglutinin disease complicating mycoplasma pneumoniae infection in a child under cytotoxic cancer treatment.

Acute cold haemagglutinin disease, most commonly associated with underlying mycoplasma infection, is rare in children. A 3-year-old girl who developed this auto-immune disease under intensive cytotoxic treatment for rhabdomyosarcoma is presented. Clinically, a livedo reticularis skin pattern upon exposure to cold which was reversible at room temperature and a spontaneous red cell agglutination of blood samples in vitro led to the diagnosis. Together with bronchopneumonia the girl developed hyper-IgM, high antibody titres against mycoplasma pneumoniae, as well as high titres of cold agglutinins. Laboratory signs of mild intravascular haemolysis were found. Positive direct antiglobulin test resulted from coating of red cells with C3d and C4. Three different antibodies were identified in serum: nonspecific cold agglutinins without complement activation, anti-I specific cold agglutinins with complement activation, as well as a weak biphasic Donath-Landsteiner haemolysin. Under antibiotic treatment and a short course of predisolone the clinical course was mild.

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6/10. erythema multiforme minor associated with mycoplasma pneumoniae infection.

A young Bedouin woman with serologically proven mycoplasma pneumoniae infection is presented. Along with pulmonary involvement, fever and bullous myringitis, she presented with erythema multiforme minor, a rare complication of mycoplasma infection of which many physicians may not be aware. The skin participation in mycoplasma infections is discussed. Mycoplasma infection should be considered in the differential diagnosis of erythema multiforme.

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7/10. Complications of the ehlers-danlos syndrome in pregnancy. A case report.

The ehlers-danlos syndrome (EDS) is a disorder of the connective tissue characterized by hyperextensible skin, loose jointedness, fragile tissues, bruising and bleeding diathesis. At least eight subtypes of EDS are recognized, each one with different clinical manifestations. On rare occasions EDS is associated with pregnancy. These patients are at risk for bleeding disorders and vascular, surgical and anesthetic complications as well as for premature labor, postpartum hemorrhage, bladder and uterine prolapse, abdominal hernias and wound dehiscence. We treated a pregnant patient for type 1 EDS and pregnancy-induced hypertension.

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8/10. association of mycoplasma pneumoniae antigen with initial onset of bronchial asthma.

Although mycoplasmal airway infection frequently exacerbates bronchial asthma, the cause of the initial onset of asthma remains unclear at present. In this report, we describe a patient in whom a previous acute mycoplasmal respiratory infection led to an initial onset of bronchial asthma. One month after the onset of the illness, cough and wheezing appeared. Pulmonary function studies revealed an airway obstructive dysfunction. Oral administration of bronchodilators resulted in a marked improvement of the asthmatic symptoms. An airway hyperresponsiveness to methacholine was demonstrated even 2 yrs after the initial onset of the illness, and IgE antibody specific to mycoplasma pneumoniae was detected in the serum by use of enzyme-linked immunosorbent assay. An immediate skin test for M. pneumoniae was positive in addition to multiple positive skin tests. A bronchial inhalation challenge test with M. pneumoniae antigen also yielded a positive result. We conclude that the effects of mycoplasmal respiratory infections on the airway are multifactorial and involve a complex interplay of airway inflammation and IgE-mediated hypersensitivity.

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9/10. Vesiculopustular eruption associated with mycoplasma pneumoniae pneumopathy.

A 43-year-old Caucasian male, hospitalised with a severe mycoplasma pneumoniae infection of the respiratory tract developed subcorneal pustular dermatosis. After 3 months of treatment with dapsone 50 mg daily, all skin lesions disappeared without recurrences.

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10/10. A pediatric case of polymyositis associated with mycoplasma pneumoniae infection.

We describe the case of a 10-year-old girl who developed polymyositis associated with a mycoplasma pneumoniae infection. She exhibited mild muscle weakness without skin rash, markedly elevated serum levels of muscle enzymes, and infiltration of mononuclear cells in a muscle biopsy specimen. Efficacy of both oral prednisolone and of intravenous methylprednisolone pulse therapy for her disease was limited. However, other immunosuppressive drugs, cyclophosphamide and methotrexate, proved clinically effective. This is the first report of steroid-resistant polymyositis associated with M. pneumoniae infection in a child.

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