AUTHOR AND EDITOR INFORMATION

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• Follow-up
• Miscellaneous
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INTRODUCTION

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Background

Mycoplasmal organisms are the smallest known free-living life forms. They are nearly ubiquitous in both the plant and animal kingdoms as colonizers and pathogens. They are prokaryotes but lack a cell wall. However, they have a unique cell membrane that contains sterols, which are not present in either bacteria or viruses. Mycoplasma organisms are small (150-250 nm) and have deformable membranes. The name Mycoplasma refers to the plasticity of the bacterial forms resembling fungal elements.

When they were first discovered, mycoplasmal organisms were believed to be viruses because they pass through filters that retain bacteria. However, unlike viruses, they are able to grow in cell-free media and contain both RNA and DNA. Mycoplasma species have also been mistakenly believed to be L-forms of bacteria, which also lack cell walls. Unlike mycoplasmal organisms, L-form bacteria do not have sterols in the cell membranes, and they can revert to their walled parental forms. The following summary is modified from Baum's "Introduction to Mycoplasma Diseases" in Principles and Practice of Infectious Diseases (see Image 1).¹

The general characteristics of Mycoplasma species include the following:

• Prokaryotic
• Size of 150-250 nm
• Lack of a cell wall
• Sterol-containing cell membrane
• Fastidious growth requirements
• Fried-egg or mulberry colonies on agar

Mycoplasma species differ from viruses in the following ways:

• They grow on cell-free media in vitro.
• They contain both RNA and DNA.
• They have both intracellular and extracellular parasitism in vivo.

Mycoplasma species differ from bacteria (including L-forms) in the following ways:

• They have sterols in the cell membrane.
• They share no DNA homology with known bacteria.
• They have low guanine levels plus cytosine content.
• Their genome has a low molecular weight.
• They exhibit no reversion to walled forms.

Pathophysiology

Mycoplasma organisms cause infection primarily as extracellular parasites, attaching to the surface of ciliated and nonciliated epithelial cells. The attachment site, or receptor, is a complex carbohydrate structurally akin to antigen I of red blood cells. The antibody response to this receptor results in production of the anti-I antibody or cold agglutinin, which acts as an autoantibody. Following attachment, mycoplasmal organisms may cause direct cytotoxic damage to epithelial cells because of hydrogen peroxide generation or cytolysis via an inflammatory response mediated by mononuclear cells or antigen-antibody reactions.

Systemic spread of the bacterium is rare. Most Mycoplasma pneumoniae–associated illnesses are confined to the respiratory tract (see Extrarespiratory manifestations for M pneumoniae infection). Genital mycoplasmal organisms are associated with a number of genitourinary tract and reproductive diseases but also can cause infections at other sites.

Mycoplasmal organisms commonly contaminate tissue cultures, in which they act as intracellular parasites and alter both cellular and viral molecular events. They are difficult to eliminate, and they raise questions regarding the validity of molecular biology results from tissue-culture experiments.

Frequency

United States

The disease is distributed worldwide. Atypical organisms such as M pneumoniae are implicated in up to 40% of cases of community-acquired pneumonia. In the United States, at least 1 case of mycoplasmal pneumonia per 1000 persons is estimated to occur each year, or more than 2 million cases annually. The incidence of nonpneumonic respiratory infection caused by Mycoplasma species may be 10-20 times higher than this.

Mortality/Morbidity

Most M pneumoniae infections lead to clinically apparent disease involving the upper respiratory tract. In 5-10% of patients (with the rate depending on age), the infection progresses to tracheobronchitis or pneumonia and is usually self-limited. Pleural effusion (usually small) occurs in 5-20% of patients. Mycoplasmas have also been implicated in the pathogenesis of asthma, leading to acute and chronic wheezing in some individuals.

Of all extrapulmonary manifestations, cardiac abnormalities are reported most frequently. In some reports, cardiac anomalies occur in as many as 10% of patients with M pneumoniae infections. Neurologic complications occur in approximately 1 per 1000 cases and usually are reversible; however, the mortality rate in patients with neurologic complications is higher than the rate in other patients. Recent reports suggest that CNS involvement is a common site in addition to the respiratory system, and may occur in up to 7% of patients hospitalized with M pneumoniae.

In individuals with sickle cell anemia, mycoplasmal infection may be severe. Unusually severe M pneumoniae infection has also been reported in children with Down syndrome.

Race

• Patients with sickle cell disease or related hemoglobinopathies are at increased risk for severe M pneumoniae infections and may develop large pleural effusions and marked respiratory distress. Those who develop extremely high cold agglutinin titers may experience digital necrosis. Since sickle cell disease and other related hemoglobinopathies are most common among African Americans, severe complications of mycoplasmal infections also occur most frequently in this group of patients.
• Genital Mycoplasma species have been isolated more frequently from African American men and women than from white men and women. Ureaplasma species are found 4 times more often than Mycoplasma hominis.

Sex

• No effect is observed according to sex of the patient on the frequency or severity of M pneumoniae infections.
• Colonization with Ureaplasma organisms and M hominis occurs primarily as a result of sexual contact. Both have been found more often in women than in men and more often in infant girls than in infant boys.

Age

• Children younger than 3 years primarily develop upper respiratory infection.
• M pneumoniae infection is uncommon in the first year of life; however in neonates, it may cause severe disease.
• M pneumoniae infection is common in school-aged children, with the highest rate of infection in individuals aged 5-20 years, in whom the tendency is to develop bronchitis and pneumonia.
• Colonization of infants by genital Mycoplasma species usually occurs during passage through an infected birth canal, and genital mycoplasmal organisms have been isolated from the upper respiratory tract in 15% of infants. Colonization usually does not persist beyond 2 years.

CLINICAL

Section 3 of 11  

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History

Symptoms of M pneumoniae infection are often nonspecific. The onset is usually insidious, with fever, malaise, headache, and cough. Cough is a hallmark of M pneumoniae infection. The frequency and severity of cough may increase over the few days after onset and may become debilitating. In patients in whom the infection progresses to lower respiratory tract disease, the original symptoms persist, with a worsening and relatively nonproductive cough. On occasion, white or blood-flecked sputum and parasternal chest pain may be present as a result of muscle strain. Otitis media and sinusitis are uncommon. Postinfectious bronchitis may persist for weeks. M pneumoniae infection may complicate asthma, and acute asthma may be the first manifestation of infection.

Infection by genital mycoplasmal organisms may have diverse manifestations, including burning micturition (nongonococcal urethritis); prostatic pain, fever, and chills (suggestive of pyelonephritis); vaginal discharge; symptoms of pelvic inflammatory disease; postpartum fever; and postabortal fever. Neonates may present with symptoms of cough, meningitis, or brain abscess.

Physical

Patients with M pneumoniae infection usually do not appear ill, and the illness often has been termed walking pneumonia. The pharynx may be erythematous without cervical adenopathy. Bullous myringitis is a classic but rare complication. Examination of the chest and lungs may yield little abnormality. A hallmark of M pneumoniae infection is the disparity between physical findings (relatively few) and radiographic evidence of pneumonia. Wheezing can occur, especially in patients with asthma. Rarely, fulminant pneumonia with respiratory failure can occur.

Physical findings of genital Mycoplasma infection vary depending on the type of infection. Neonates, especially premature infants, may present with wheezing, retractions, and respiratory failure or signs of meningitis/brain abscess (eg, seizures, lethargy, neurologic deficits).

Extrarespiratory manifestations of M pneumoniae infection include the following:

• Dermatologic manifestations (most common)
• • Erythematous macular and/or morbilliform rash
  • Erythema multiforme or Stevens-Johnson syndrome
  • Erythema nodosum
• Urticarial manifestations
• • Papulovesicular exanthem
  • Raynaud phenomenon
• Cardiac manifestations
• • Arrhythmia and/or ECG abnormalities (conduction defects)
  • Congestive failure
  • Pericarditis
  • Myocarditis
  • Endocarditis
• Neurologic manifestations
• • Cranial neuropathy
  • Aseptic meningitis or meningoencephalitis
  • Transverse myelitis
  • Brainstem dysfunction
  • Dysfunction of the pyramidal or extrapyramidal tract
  • Cerebellar dysfunction
  • Cerebral infarction
  • Guillain-Barré syndrome
  • Peripheral neuropathy
• Musculoskeletal manifestations
• • Polyarthralgias
  • Acute arthritis (monoarticular or migratory)
  • Digital necrosis
• Hematologic manifestations – Immune hemolytic anemia

Causes

• M pneumoniae causes infections leading to clinically apparent disease involving the upper respiratory tract. In 5-10% of patients, depending on age, the infection progresses to tracheobronchitis or pneumonia.
• M hominis causes genital mycoplasmal infections, which may result in diverse manifestations.

DIFFERENTIALS

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Other Problems to be Considered

M pneumoniae infection

Respiratory viral infections (especially those due to adenovirus, parainfluenza and influenza viruses, rhinoviruses, coronaviruses, respiratory syncytial virus, human metapneumoviruses)
Chlamydia pneumoniae infection
Legionella infection
Q fever
Spotted fever caused by Rickettsia rickettsii

Infection with genital Mycoplasma species

Chlamydia trachomatis infection
Neisseria gonorrhoeae infection

WORKUP

Section 5 of 11  

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Lab Studies

• Tests for M pneumoniae
• • Bacterial culture is of little practical value because of fastidious growth requirements and slow growth.
  • Serologic diagnosis has been the mainstay of laboratory testing.
    • The cold agglutinin test may be performed at the bedside or in the laboratory. Plasma from spun patient serum is combined with type O erythrocytes and incubated at 4°C for several minutes. The degree of agglutination is noted at this temperature and again after rewarming to 37°C to confirm resolution of the agglutination. The serum is diluted serially, and the test is repeated. The highest dilution resulting in agglutination at 4°C is reported as the cold agglutinin titer.
    • Paired acute and convalescent sera are best for complement-fixation serology. The test is more specific than the cold agglutinin test but is not helpful in guiding diagnostic and therapeutic decisions.
    • Enzyme-linked immunoassay is used to detect immunoglobulin M (IgM) and immunoglobulin G (IgG) directed against M pneumoniae. Specificity is greater than 99%, and sensitivity is 98% when both findings are obtained. The IgM result may be negative early (at 7-10 d) and may not be helpful in guiding initial therapy.
  • Direct antigen detection in sputum specimens is performed using antigen-capture indirect enzyme immunoassay. Relatively high specificity and sensitivity (91%) are achieved.
  • Detection of nucleotide sequences with a commercially available kit is based on radioiodine-labeled DNA complementary to M pneumoniae ribosomal RNA. Sensitivity and specificity were 89% in 1 study.
  • Seminested polymerase chain reaction (PCR) assay using 16S ribosomal DNA (rDNA) as a target and real-time PCR assays targeting the gene for P1 adhesion protein are available. They do not rely on an immunologic response; therefore, relatively early detection is possible. Both techniques have high sensitivity and high specificity. Real-time PCR assays have the advantage of speed and the ability to analyze numerous samples.
• Tests for genital mycoplasmal organisms
• • These organisms are usually detected by means of cultures in special media (beef-heart infusion broth with fresh yeast extract and horse serum), followed by subcultures on agar media. Ureaplasma species usually grow within 1-2 days, and M hominis grows within 1 week, but Mycoplasma genitalium may require 1-2 months to grow.
  • Antibody studies, organ cultures, and animal inoculation have all been used, but they have little practical application in routine diagnostic laboratories. PCR techniques using clinical specimens from the upper genital tract obtained during laparoscopy may be of value in the future.

Imaging Studies

• Chest radiographs demonstrate characteristic features of M pneumoniae infection: bilateral pulmonary involvement, multifocal or diffuse disease, and reticular infiltrates. In rare cases, pleural effusions may be superimposed on parenchymal disease. Late in the course, pleural effusions may be the only remaining feature. However, radiologic appearances can be diverse and mimic those of other bacterial pneumonias.
• High-resolution CT may reveal the lobular distribution, centrilobular involvement, and interstitial abnormalities in M pneumoniae pneumonia better than chest radiography. However, high-resolution CT is more expensive, and radiation exposure is increased. High-resolution CT is usually not indicated in the routine workup of all patients.

Procedures

• Because most infections tend to be mild, few diagnostic procedures need to be performed.
• In severe lower respiratory infection caused by M pneumoniae, bronchoalveolar lavage with appropriate testing of the lavage fluid may be needed; antigen detection, PCR, and culturing are used.

Histologic Findings

The histopathology of M pneumoniae infection is limited to the ciliated respiratory epithelium extending from the trachea to the respiratory bronchiole. The airways are surrounded by mononuclear cell infiltrates. Intraluminal infiltrates may include polymorphonuclear cells and mononuclear cells.

TREATMENT

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Medical Care

• Antimicrobial therapy is not necessary for mycoplasmal infection of the upper respiratory tract.
• Although pneumonia is self-limiting and is not life threatening in most patients, treat it with appropriate antimicrobials to shorten the duration of illness and perhaps reduce spread to contacts.
• Management of genitourinary diseases in which Mycoplasma species may play a role depends on recognizing the clinical syndromes for which antimicrobial therapy may be appropriate. Consider using antimicrobials that are active against mycoplasmal organisms in nongonococcal urethritis and pelvic inflammatory disease.

Surgical Care

Surgical treatment is typically not needed.

Consultations

Although consultations are usually not needed, in severe cases, admission to the intensive care unit and consultation with critical care specialists, pulmonologists, and infectious disease physicians may be warranted. In patients who present with extrarespiratory manifestations, consult appropriate subspecialists.

Activity

Activity is as tolerated by the patient.

MEDICATION

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As a result of the lack of a cell wall, beta-lactams are ineffective; neither is the combined therapy of trimethoprim and sulfamethoxazole effective. Aminoglycosides are effective in vitro, but efficacy is unknown in vivo.

Ketolides are in development and show effective activity against mycoplasmal organisms. Telithromycin, a recently-licensed ketolide, has been shown to be active against M pneumoniae. It is approved for treatment of community-acquired pneumonia. Because of the risk of hepatotoxicity associated with telithromycin, the US Food and Drug Administration (FDA) removed previously approved indications for sinusitis and acute bacterial exacerbations of chronic bronchitis.

Streptogramins (ie, quinupristin-dalfopristin) are available only as a parenteral formulation; therefore, they are not practical for use in patients with Mycoplasma diseases.

Macrolides are the agents of choice. Alternatively, tetracyclines may be used in patients older than 8 years. Fluoroquinolones may be considered if macrolides or tetracyclines are not suitable choices; however, most fluoroquinolones are not approved by the FDA for use in patients younger than 18 years.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Whenever feasible, guide antibiotic selection using culture sensitivity.

FOLLOW-UP

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Further Inpatient Care

• Further inpatient care is usually necessary only if severe pneumonia or extrarespiratory complications occur.

Further Outpatient Care

• Routine follow-up visits are usually not required because the response to therapy is generally excellent.

In/Out Patient Meds

• See Medical Care.

Transfer

• Transfer is usually necessary only if severe pneumonia or extrarespiratory complications occur and if appropriate medical facilities for treatment are not available locally.

Complications

• Complications are relatively rare.
• See Extrarespiratory manifestations of M pneumoniae infection.

Prognosis

• Prognosis for Mycoplasma infections is usually excellent; however, if complications occur, long-term sequelae may result.

Patient Education

• Patient education regarding the common occurrence, relatively mild nature, appropriate therapy, and usually complete recovery from Mycoplasma infection is important.

MISCELLANEOUS

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Medical/Legal Pitfalls

• No special considerations pertain to M pneumoniae infections.
• Possible sexual abuse is a concern when genital Mycoplasma infections occur in children older than 2 years, but investigate these cases with care because Mycoplasma species are ubiquitous.

MULTIMEDIA

Section 10 of 11  

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Media file 1:  General characteristics of Mycoplasma species.
	View Full Size Image
Media type:  Graph

REFERENCES

Section 11 of 11

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Article Last Updated: Aug 8, 2007