Abstract

        We report a case of Mycoplasma Pneumonia complicated with severe hemolytic anemia, which occurred as a result of a high titre of cold agglutinin. A 30 yearold male was admitted because of fever, jaundice and dyspnea. Chest x-ray showed diffuse small nodular infiltrates throughout both lung fields. Laboratory studies disclosed the following values: Hb 6 g/dl, Hct 16.4%, reticulocyte 10%, leukocytes 49x109/L, direct and indirect Coombs’ test were positive, ESR 116 mm/hr, cold agglutinin titre 1:1800, mycoplasma antibody titre 1:640. The diagnosis of autoimmune hemolytic anemia associated with Mycoplasma Pneumonia was made, and treatment with Erythromycin and Prednisolone observed striking clinical improvement. It was suggested that the cold exposure was possibly a major factor in the pathogenesis of hemolysis in this patient. Conclusion: (1) Mycoplasma Pneumonia patients would be highly suspected to be associated with cold agglutinin disease. (2) Corticosteroids and erythromycin are effective in treating severe hemolytic anemia associated with mycoplasma pneumonia.

Key words: Mycoplasma Pneumonia, Hemolytic, Agglutinin.

Introduction

      Mycoplasma Pneumoniae is a common cause of atypical pneumonia in children and young adults. The infection is generally mild and only a very few patients are admitted to hospital. However, extrapulmonary complications are well recognized, mostly as manifestations from the central nervous system..

 

Case Report


       A thirty-year-old man was admitted complaining of general weakness, difficulty with breathing associated with mild fever and cough . Three days later the patient developed a yellowish discoloration of the sclera then the whole body. He had no recent history of taking drugs, medicines or blood transfusions On examination he appeared anxious, well oriented, febrile, jaundiced; his temperature was 37.6 0C, pulse rate 110/minute, BP: 90/60 and regular respiratory rate 24/minute.
Chest X-ray showed diffuse small nodular infiltrates throughout both lung fields. Laboratory studies disclosed the following values: Hb 6 g/dl, Hct 16.4%, reticulocyte 10%, Leukocytes 49X109/L with a shift to the left and presence of 7 nucleated RBC/100 leukocytes, ESR 116 mm/hr. A blood smear show red blood cell aggregations and the presence of hypersegmented neutrophils. The direct and indirect Coombs’ tests were positive, cold agglutinin titre was 1:1800, mycoplasma antibody titre 1:640, indirect bilirubin 64.6 µmol/l and LDH 750 iu/L.
After one week of treatment with oral prednisolone, erythromycin, folic acid and avoiding cold exposure, the symptoms disappeared and most of the blood results were gradually corrected; see Table 1..
 

Figure 1: Chest radiograph of mycoplasma pneumoniae in both lung fields with diffuse small nodular infiltrates

 

Figure2: Blood smear of mycoplasma pneumoniae with red blood cells aggregation and hypersegmented neutrophils

Discussion


       Mycoplasma pneumoniae is a unique bacterium that does not always receive the attention it merits considering the number of illnesses it causes, and the degree of morbidity associated with it, in both children and adults. Serious infections requiring hospitalization, while rare, occur in both adults and children and may involve multiple organ systems (1). This disease can be an acute, transient disease mostly seen in younger people or a chronic disease primarily in older patients. It is typically caused by an IgM antibody, and the Coombs test will only be positive for C3, because the IgM will not be attached to the RBCs at warmer temperatures. The acute form of this disease is mostly seen in patients with Mycoplasma pneumonia. The IgM antibodies are directed against the I, or i, antigen on the RBC surface, respectively. Only rarely do patients develop significant hemolysis but severe anemia and renal failure can occur. The severity of disease appears to be related to the degree to which the host immune response reacts to the infection (2-4). Extra-pulmonary complications involving all of the major organ systems can occur in association with mycoplasma pneumoniae infection as a result of direct invasion and/or autoimmune response. The extra-pulmonary manifestations are sometimes of greater severity and clinical importance than the primary respiratory infection (5,6).
Development of auto-antibodies to intracellular molecules is a universal feature of autoimmune diseases and parallels the onset of chronic inflammatory pathology (7). Initiating antigens of disease-specific auto-antibody responses are unknown.
It is suggested that cold exposure is, possibly, a major factor in the exaggeration of clinical and hematological manifestations (8). The treatment of hemolytic anemia, and cold agglutinin secondary to mycoplasma pneumonia with erythromycin and prednisolone observed striking clinical and hematological improvement (9).
We concluded that mycoplasma pneumonia infection is highly suspected to be associated with cold agglutinin disease and that cold exposure will exaggerate the clinical and hematological manifestations. Corticosteroid and erythromycin are effective in treating severe hemolytic anemia associated with mycoplasma pneumonia..

 

References

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5. Ben Aissa-Fennira F, Bouguerra A, Hafsia R, et al.
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6. Plotkin GR, Slovak JP Jr, Lentz PE. Mycoplasma pneumonia
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8. Inoue F, Miyake N, Yamasowa M, et al. Cold agglutinin
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