Cerebral infarction associated with Mycoplasma pneumoniae infection in a child

Abstract

A previously healthy 5-year-old girl was referred with a 2-day history of acute onset neurological symptoms and hypodense areas in the left cerebellar hemisphere and basal ganglia on brain computed tomography (CT). The child had developed a high fever and dry cough 11 days prior to admission and was treated for 4 days with oral cefaclor, (30 mg/kg/day) followed by oral azithromycin (10 mg/kg/day), and intravenous ceftazidime (100 mg/kg/day) for 5 days at the local health-care facilities. Her past medical and family histories were unremarkable. On admission, she had dysarthria, dysphagia, and weakness of the left-side of the body. She did not develop headache, aches in muscles or joints, nausea and vomiting, confusion and agitation, or even seizures and loss of consciousness. Physical examination revealed that she was drowsy and subfebrile, but her vitals were stable with a blood pressure of 100/70 mmHg. Right lung breath sounds were reduced, with a few crackles. Neurological examination showed diminished muscle strength, brisker tendon reflexes, Babinski reflex, and normal sensation on the left arm and leg. Her memory and ability to calculate were intact. The brain CT finding was confirmed by magnetic resonance imaging (MRI), which showed multiple foci of abnormal increased signal on fluid attenuated inversion recovery and diffusion weighted imaging sequences as well as apparent diffusion coefficient maps in the right brainstem, the left thalamus and the left cerebellum (Fig. 1a– i). Brain magnetic resonance angiography (MRA) revealed a decreased signal in the right posterior communicating artery trajectory, which may be due to the occlusion caused by the infarction (Fig. S1). A chest X-ray revealed right upper and right middle lobe consolidation with a small volume of pleural effusion (Fig. S2a). A transthoracic echocardiogram revealed intracardiac thrombus as a hyperechogenic and mobile mass, firmly attached to the posterior wall of the right ventricle (Fig. S3a). Pelvic and lower extremity Doppler ultrasound examinations showed a nonocclusive thrombus in the left common femoral vein (Fig. S3b). Coagulation studies showed an elevated prothrombin time of 19.8 s (reference < 12.1) and D-dimer of 22.02 mg/L (reference < 0.55), with absent anticardiolipin, antinuclear, and anti-DNA antibodies. Lumbar puncture showed clear and colorless cerebrospinal fluid (CSF) with a slight increased leukocyte count (16 9 10 cells/L), with normal total protein content (0.18 g/L), glucose concentration (4.1 mmol/L), and chloride concentration (125 mmol/L). Antibody titer to Mycoplasma pneumoniae, determined by the enzyme-linked immunosorbent assay (ELISA), was IgM 1:1280 1 day post admission, followed by IgM 1:80 3 weeks later. Quantitative real-time polymerase chain reaction of the oropharyngeal swabs, bronchoalveolar lavage, and CSF identified 1.3 9 10, 4.0 9 10, and 1.4 9 10 DNA copies per mL of Mycoplasma pneumoniae, respectively. Blood and CSF cultures were negative. With a working diagnosis of acute cerebral infarction after Mycoplasma pneumoniae infection, antibiotics (intravenous meropenem, 60 mg/kg/day; oral minocycline, 4 mg/kg/day), steroid (intravenous methylprednisolone, 2 mg/kg/day), and anticoagulant regimen (subcutaneous low-molecular-weight heparin, 2,000 to 6,000 IU/day to maintain an activated partial thromboplastin time twice the control for 3 weeks; heparin was replaced with oral aspirin, 1 mg/kg/day for 1 month) were instituted. The child was discharged after a 4-week hospital stay with full clinical and radiological resolution (Fig. S2b). Neurological function was normal at the 3 month follow-up. Cerebral infarction is a rare and severe neurological complication of Mycoplasma pneumoniae infection. It is commonly manifested as hemiparesis and dysarthria, but has also been associated with facial palsy, without changes in mental status. A review of the pediatric cases of cerebral infarction after Mycoplasma pneumoniae infection was reported by Jin et al. Stroke events most frequently involved anterior brain circulation, either the internal carotid artery or the middle cerebral artery and, rarely, posterior circulation, as in our case. The approach to multimodal treatment was similar to ours, the outcomes reported varying from death to full Correspondence: Yucai Zhang, PhD, Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University, 1400 West Beijing Road, Shanghai 200040, China. Email: [email protected] Guodong Ding and Dandan Song contributed equally to the study. Received 12 June 2020; revised 21 September 2020; accepted 22 October 2020. doi: 10.1111/ped.14524