Acute Mycoplasma pneumoniae Infection Presenting as Cholestatic Hepatitis

Abstract

A previously healthy 35-year-old man presented with fever, coughs, and jaundice. After flu-like symptoms for 2 weeks, the patient developed mild jaundice and high fever. On admission to our hospital, the physical examination revealed scleral jaundice and was otherwise unremarkable. Body temperature was 39.5°C. Chest X ray showed a patchy dense infiltration of the right lower lobe. Abdominal ultrasound showed small bilateral pleural effusions and minimal ascites. Abnormal laboratory findings on admission included alanine aminotransferase (ALT), 79 U/liter (normal, Ͻ23 U/liter); bilirubin, 2.8 mg/dl (normal, Ͻ1.2 mg/dl); alkaline phosphatase, 753 U/liter (normal, Ͻ200 U/liter); serum albumin, 2.7 g/dl (normal, Ͼ3.5 g/dl); and international normalized ratio, 2.1 (normal, 1.0).Known causes of acute hepatitis were excluded: anti-hepatitis A virus immunoglobulin M (IgM), negative; HBsAg and anti-HBc, negative; anti-HCV, negative; anti-nuclear antibodies, Ͻ1:10; antimitochondrial antibodies, negative; antismooth-muscle antibodies, negative; and no evidence for acute infection with herpes simplex virus, cytomegalovirus, or Epstein-Barr virus. Further, there was no evidence for hemochromatosis or WilsonЈs disease. Alcoholic or drug-induced hepatitis was excluded by the patientЈs history.Further serologic workup revealed acute infection with Mycoplasma pneumoniae (IgG enzyme immunoassay [EIA], 263 U/ml; IgA EIA, 162 U/ml; IgM EIA, 338 U/ml (titers of Ͼ64 U/ml are considered positive). Antibiotic therapy was started with cefuroxime given intravenously; 1 day later, therapy was changed to clarithromycin (500 mg orally twice daily for 3 weeks), resulting in a quick improvement of the patientЈs clinical condition. Ten days after the initiation of the antibiotic therapy, the pulmonary infiltration had disappeared. Liver function tests also improved quickly (Fig. 1), except for the ALT elevation, which persisted about 6 months before returning to normal levels.Infection with M. pneumoniae primarily affects the respiratory tract. Symptoms range from mild fever and nonproductive cough to severe pneumonia. Extrapulmonary manifestations include the central nervous system as well as the cardiovascular, gastrointestinal, and hematological systems (1,2,5,6). This case demonstrates that hepatobiliary involvement of M. pneumoniae can occur in the immunocompetent adult. Hepatobiliary involvement of M. pneumoniae infection was confirmed by the close temporal association of impaired liver function test results with clinical and radiological findings typical for M. pneumoniae infection and the exclusion of other causes of cholestatic hepatitis. To date, M. pneumoniae-associated cholestatic hepatitis has been reported only for children (1-3). The pathogenesis of extrapulmonary disease in M. pneumoniae infection is poorly understood. Possible mechanisms include infection of epithelial cells as well as an immune-mediated damage by cross-reactive anti-M. pneumoniae antibodies. A well-described feature of mycoplasma infection is the development ...

Clinical Characteristics of Patients with Mycoplasma pneumoniae-Related Acute Hepatitis

“…The wide range of incidences of M. pneumoniae- related hepatitis reported may be due to the retrospective nature of these previous studies and/or the diverse definitions of hepatitis used in these different studies. The most well-recognized manifestation of M. pneumoniae -related hepatitis is elevation of ALT levels, while a few case reports of cholestatic hepatitis have been also documented [14,15,16]. In the current study, we observed that M. pneumoniae infection affected the hepatobiliary system of 21% of patients with M. pneumoniae infection.…”

Pathogenesis of extrapulmonary manifestations of Mycoplasma pneumoniae infection with special reference to pneumonia

“…This implies that early-onset hepatitis, which sometimes occurs in the absence of pneumonia [20,34,38], is a direct-type extrapulmonary manifestation in which hematogenously transferred M. pneumoniae causes inflammation through the function of cytokines at the local site. Late-onset hepatitis, on the other hand, might have a multifactorial pathomechanism [34,36], involving such cases as autoimmunity, vascular injury, and drug allergy, the last of which is not a true complication of M. pneumoniae infection. In addition, it is of some interest that liver dysfunction is more frequently observed in patients with pleural effusion than in patients without [37,39], suggesting that there is a certain common etiologic factor underlying both pleural fluid production and liver dysfunction in particular patients.…”

“…Hepatic involvement, such as encephalitis [1], is likely to be bimodal: early-onset hepatitis, in which liver dysfunction is evidently observed at the first visit to the hospital, and late-onset hepatitis, in which liver dysfunction becomes evident later in the course, 7-10 days after the onset of fever [34][35][36][37]. Concerning early-onset hepatitis, the author and coworkers showed that mycoplasmal bacteraemia might be a prerequisite [20].…”

Mycoplasma pneumoniaeand Its Role as a Human Pathogen

“…These include nausea, vomiting, and diarrhea. Rarely, cholestatic hepatitis and pancreatitis have been associated with respiratory infections (11,174,381,386).…”