Atypical (walking) pneumonia

8/4/2019 Atypical (walking) pneumonia

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Morning Report

Elisabeth Kaza

Monday, 08/22/2011



July in the ED…

• 12Y 6M F with cough for ~ 1 week followed by

severe headache

• Low grade fever on and off

• Seen by PCP

– gave augmentin for positive strep

– then noted SOB and low O2 sat in office

– send her to ED for further work- up



July in the ED…

• In the outside ED:

– O2 sats in 30s, tachypneic, placed on

nonrebreather mask with improved sats to 70s-

80s

– Then transitioned to CPAP with PEEP 8 at 100%

FiO2 with O2sat of 92%

–

Tachycardic with temp of 38.1• Transport via Life Flight to PCMC PICU



More info…

• PMH: 28 week premature infant, twin A. 54

day NICU stay, was sent home with O2 x

several weeks. Long h/o migraines.

• SURGERIES: PDA ligation (NICU stay)

• IMMUNIZATIONS: UTD

•

MEDS: none• ALLERGIES: none



More info…

• FH: Mom with migraines. Sister with recent

cough 2 weeks ago.

• SH: Lives in Blanding, UT with mom. But has

been in Spanish Fork, UT for vacation. Twin

sister, 2 younger brothers. Dad is involved.

• Exposures:

– No travel outside Utah

– No exposure to TB



Physical Exam

• VITALS in the ED:

– T: 38.1, HR: 140, RR: 35, BP: 113/65, O2sat: 87%

on 15L FM.

– Height and weight: appropriate for age

• GEN: awake, alert, respiratory distress

• HEENT: NC/AT, MMM

• CV: RRR, tachy, no murmur, cap refill <2sec



Physical Exam

• RESP: tachypneic, coarse breath sounds

bilaterally (not focal), no wheezing

• ABD: soft, NT, ND, no masses

• NEURO: CN II-XII intact, 5/5 strength

• SKIN: no rashes, pink



Differential

• Infectious: Bacterial Pneumonia, Viral pneumonia (adenoviruses,

parainfluennza, influenza), Tuberculosis, Fungal pneumonia, PCP

(Pneumocystis pneumonia), Chlamydia pneumonia, Coxiella burnetii (Q

fever), Legionella pneumonia, Anthrax, Tularemia, Plague, Histoplasmosis,

Cryptococcus

• Respiratory: Empyema, Abscess, Pneumothorax, Pulmonary embolism,

Aspiration of foreign body, Asthma, Bronchiolitis, Bronchiectasis, Pertussis

• Chemical: Aspiration Pneumonia/Inhalation injury

• Cardiac: CHF, R--->L shunting, pulmonary HTN

•Damage by physical agents: Lipoid pneumonia, Kerosene pneumonia, Neardrowning, Smoke inhalation

• CNS: stroke, tumor, CNS infection (headache)



Laboratory

• WBC 5.5 (9B, 64N, 21L, 1M), Hct 33.6, Plts 248

• CRP 2.0

•

BNP 257, Troponin 0.1• ABG 7.44/39/51/26/2.1

• Lactate 1.3

• Na 135, K 40, Cl 103, CO2 26, BUN 8,Creatinine 0.45, Ca 7.7, Glc 128



Laboratory

• Tox screen negative

• DFA/VRP negative

•

Mycoplasma Pneumonia PCR detected• Blood culture NGTD

• CBC on d/c: WBC 6.1 (1B, 62N, 30N, 5M, 2E),

Hct 44.1, Plts 583



Initial Imaging

• CXR (admission): diffuse heterogeneous

pulmonary opacities, mild cardiomegaly, PDA

clip

• CXR (discharge): near complete resolution of

pulmonary infiltrates

• ECHO: Trace TV regurgitation, normal

ventricular septum motion, normal LV/RV size

and function. Bubble study normal



CXR on admission (portable)



During PICU stay



And upon discharge…



Hospital Course

• Outside ED:

– CBC, BMP, ABG with Lactate, VRP, blood culture

obtained

– NS bolus was given. CXR obtained

– 2 gm Rocephin, 400mg IV azithromycin given



Hospital Course

• PICU and inpatient floor:

– CPAP with PEEP 8, then increased to 12. Tox

screen for potential linear pneumonitis. NPO given

respiratory status. Azithromycin and Rocephincontinued. Echo done. Slowly weaned on her FiO2

to HFNC, then to NC and d/c on RA

– Mycoplasma detected. Azithromycin x 5 days

– CBC initially: lymphopenia, resolved upon d/c

– BNP also normalized 257 --> 19



Atypical (walking) pneumonia

• H/o oxygen for a few weeks after d/c from

NICU suggests that she has less pulmonary

reserve, may explain degree of hypoxia

• Caused by Mycoplasma pneumonia



M. pneumoniae

• Smallest bacteria that can survive alone,

lacking cell wall

• Prevalence:

– 30% in outpatient setting

– 15% inpatient

• Transmitted from person to person by infected

respiratory droplets

• School age kids



Laboratory Diagnosis

Diagnostic test Material Sens % Spec % Result Time Cost

Cold agglutinins Serum 30-50 50 variable low

Culture NPA-PS 61 100 2-6 weeks low

ELISA Serum 83-100 79-100 Hours - 2 wks moderate

DNA probe NPA-PS 89-100 89-98Hours - 2 wks

moderate/high

PCR NPA-PS 78-100 92-100 Hours–

1 wk moderate/high

Sens = Sensitivity. Spec = Specificity. NPA = nasopharyngeal aspirate. PS = Pharyngeal swab



Manifestation Frequency observed

Fever ++++

Cough ++++

Crackles on CXR +++Malaise +++

Headache ++

Sputum production ++

Sore throat/pharyngitis ++

Chills +

Hoarseness +Earache +

Coryza +

Diarrhea +

Nausea/vomiting +

Chest pain +Lymphadenopathy +

Skin rash +



Chronology of M. pneumonia

Incubation Clinical illness Convalescence

SYMPTOMS Headache,

Malaise

Fever

Sore throat

Cough

SIGNS Sputum

Dullness

Rales

LABORATORY Positive culture

CXR findings

Weeks



Treatment

• Usually benign – Macrolide

• Severe life-threatening pneumonia possible

(defined as refractory MP showing clinical/rad.

deterioration after macrolide tx. Can try

Ciprofloxacin (cartilage toxic) plus

glucocorticoid



References

• Combined treatment for child refractory Mycoplasma pneumoniae Pneumonia with ciprofloxacin and

glucocorticoid. Lu A, Wang L, Zhang X, Zhang M. 3Pediatr Pulmonol. 2011 Jun 22. doi: 10.1002/ppul.21481.

• Infection by Mycoplasma pneumoniae and its importance as an etiological agent in childhood community-

acquired pneumonias. Vervloet LA, Marguet C, Camargos PA. Braz J Infect Dis. 2007. Oct; 11(5):507-14.

• Advance in the diagnosis and treatment of Mycoplasma pneumoniae pneumonia and related complications. Zhang

YM, Liu XY. Zhongguo Dang. 2011 Apr;13(4):358-60. Review.

• Pneumonia in the immunocompetent patient. Reynolds JH, McDonald G, Alton H, Gordon SB. Br J Radiol. 2010.

Dec, 83 (996)”998-1009.• Community-acquired pneumonia in children: what’s old? What’s new? Don M, Canciani M, Korppi M. Acta

Paediatr. 2010 Nov;99)11):1602-8.

• The first atypical pneumonia: the history of the discovery of Mycoplasma pneumoniae. Cunha CB. Infect Dis Clin

North Am. 2010. Mar; 24)1):1-5.

• Macrolide-resistant Mycoplasma pneumoniae: characteristics of isolates and clinical aspects of community-

acquired pneumonia. Morozumi M, Takahashi T, Ubukata K. J Infect Chemother. 2010 Apr; 16(2):78-86.

Mycoplasma pneumoniae infection in a clinical setting. Othman N, Isaacs D, Daley AJ, Kesson AM. Pediatr Int.

2008.

• Medical Microbiology. 4th edition. Baron S, editor. Galveston (TX):; 1996. Chapter 37. Mycoplasmas. Shmuel

Razin.Ver

http://www.ncbi.nlm.nih.gov/pubmed/17962878

http://www.ncbi.nlm.nih.gov/pubmed/17962878

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Atypical (walking) pneumonia