INSTRUCTIVE CASES

Necrotizing Pneumonitis Caused by Mycoplasma

pneumoniae in Pediatric Patients
Report of Five Cases and Review of Literature
Ruay-Shyang Wang, MD,† Shuo-Yu Wang, MD,* Kai-Sheng Hsieh, MD,* Yee-Hsuan Chiou, MD,*
I-Fei Huang, MD,* Ming-Feng Cheng, MD,* and Christine C. Chiou, MD‡

right lower lung field. A chest radiograph showed consolida-

Abstract: Mycoplasma pneumoniae infection is usually self-limited
without severe sequelae. We report 5 pediatric patients with necro- tion of the right middle lobe with moderate pleural effusion
tizing pneumonitis caused by Mycoplasma pneumoniae and re- (see Table 1 for laboratory data). The C-reactive protein
viewed the reported cases in the English language. Protracted course concentration was 3.6 mg/dl (normal range ⬍ 0.6 mg/dl). A
of fever and respiratory distress were noted in all 5 patients. computed tomography (CT) of the chest showed total con-
Macrolides and adequate chest tube drainage for pleural effusion solidation of the right middle lobe with a low attenuation
were the mainstay of treatment. area, consistent with necrotizing pneumonitis and a large
Key Words: Mycoplasma pneumoniae, necrotizing pneumonitis, amount of right-sided pleural fluid (Fig. 1). A chest tube was
pediatric patients inserted for pleural fluid analysis and drainage. The pleural
fluid was yellow and not turbid. Analysis of pleural fluid is
(Pediatr Infect Dis J 2004;23: 564 –567)
shown in Table 1. No organisms were seen on Gram- and
acid fast-stained smears. Blood and pleural fluid cultures did
not yield bacteria, fungi or tuberculosis organisms. The com-

M ycoplasma pneumoniae, a common pathogen of com-

munity-acquired pneumonia, usually follows a benign
course.1 Pneumonia caused by Mycoplasma pneumoniae usu-
plement fixation antibody titer for M. pneumoniae was 1/320.
The fever subsided within 3 days after administration of
azithromycin (10 mg/kg/day for 3 days). A pneumatocele was
ally resolves without serious complications. The radiographic present on the chest roentgenogram taken 47 days after
findings of Mycoplasma pneumoniae pneumonia are variable; admission and persisted for 180 days of follow-up.
haziness or ground-glass consolidation occurs most fre- Case 2. This 6 -year-old girl was well in the past. She had
quently. Atelectasis, nodular infiltration and hilar adenopathy fever, cough and rhinorrhea for 7 days and shortness of breath
are also often encountered.2 Necrotizing pneumonitis, how- for 2 days before admission. The body temperature was
ever, is a rare manifestation of M. pneumoniae infection.3 We 39.5°C, the pulse rate 137 beats/min and the respiratory rate
report 5 pediatric patients with M. pneumoniae infection 50/min on admission. Rhonchi and rales were heard with
complicated with necrotizing pneumonitis. decreased breath sounds over the left lower lung. Tachypnea
with subcostal retraction was also present. A chest radiograph
REPORT OF CASES showed total opacity of the left lung with massive pleural
Case 1. A 14-year-old girl was hospitalized because of fever effusion (see Table 1 for laboratory data). The C-reactive
and dyspnea. Decreased breath sounds were found over the protein concentration was 98.3 mg/dl. Diagnostic thoracocen-
tesis and chest tube insertion were performed. Analysis of
pleural fluid is shown in the table. No organisms were seen on
Accepted for publication January 6, 2004.
From the *Department of Pediatrics, Kaohsiung Veterans General Hospital,
Gram and acid-fast stains. The latex agglutination test of the
Kaohsiung, Taiwan; the †Department of Pediatrics, Yungkang Veterans pleural fluid for Streptococcus pneumoniae, Haemophilus
Hospital, Tainan, Taiwan; and the ‡Department of Pediatrics, National influenzae type b and group B Streptococcus was negative. A
Yang-Ming University, Taipei, Taiwan CT of the chest disclosed consolidation of the left lingular
Address for reprints: Christine C. Chiou, MD, Department of Pediatrics, lobe with diffuse and severe necrosis. A chest tube was
Kaohsiung Veterans General Hospital, 386, Ta-Chung 1st Rd, Kaohsiung
813, Taiwan. Fax 886-7-3468207; E-mail [email protected]
placed with effective drainage of the pleural effusion (Fig. 2).
Copyright © 2004 by Lippincott Williams & Wilkins The M. pneumoniae complement fixation titer was 1/1280.
DOI: 10.1097/01.inf.0000130074.56368.4b The cold hemagglutinin titer was 1/128. Azithromycin was

564 The Pediatric Infectious Disease Journal • Volume 23, Number 6, June 2004
The Pediatric Infectious Disease Journal • Volume 23, Number 6, June 2004 Mycoplasma Necrotizing Pneumonitis

TABLE 1. Laboratory Data of the 5 Patients with

Mycoplasma pneumoniae Necrotizing Pneumonitis

Patient
Test
1 2 3 4 5

Serum
Leukocyte count (103/mm3) 10.67 13.62 10.2 25.01 6.31
Neutrophils (%) 66 72 91 74 52
Band cells (%) 0 18 0 14 0
Lymphocytes (%) 24 8 9 9 37
Hemoglobin (g/dl) 12.5 11.6 11.8 11.1 11.5
Platelet count (103/mm3) 363 197 96 88 81
Aspartate aminotransferase 41 176 178 4,090 22
(IU/l)
Alanine aminotransferase 117 159 50 3,337 10
(IU/l)

Pleural fluid
Leukocyte count (/mm3) 690 1,000 2,800 990 NT FIGURE 2. Contrast-enhanced CT at 9th day of fever. The left
Neutrophils (%) 14 8 8 80 NT
Lymphocytes (%) 86 92 92 20 NT lingular lobe shows low-attenuation change with strongly en-
Erythrocyte count (/mm3) 840,000 130,000 207 720 NT hanced pulmonary vascularity, indicating diffuse and severe
Protein (g/dl) 3.8 4.9 3.6 4.1 NT necrosis of the lung. Thoracotomy tube is placed with effective
Lactate dehydrogenase 2,320 8,408 2,149 3,216 NT
(IU/l) drainage of the pleural fluid.
NT, Not tested.

radiograph showed consolidation with right pleural effusion

and increased infiltration in the left lung. Laboratory values
are shown in Table 1. The sedimentation rate was 47 mm/h,
and the C-reactive protein concentration was 51.3 mg/dl. A
CT of the chest showed consolidation over the right middle
lobe with pleural effusion and central necrosis in the right
middle lobe (Fig. 3). Diagnostic thoracocentesis and chest
tube insertion were performed. The pleural fluid was yellow
and not turbid. Analysis of pleural fluid is shown in Table 1.
No organisms were found on Gram- and acid fast-stained
smears. Vancomycin and cefotaxime were prescribed, but
spiking high fever and pleural effusion persisted for 2 weeks.
Cultures for bacteria, Mycobacterium tuberculosis, fungi and

FIGURE 1. Computed tomography (CT)of chest shows consol-

idation of the right middle lobe with low attenuation area,
indicating necrosis in the pneumonia. Large amount of right-
sided pleural effusion is also noted.

administered for 7 days. The fever persisted for 20 days

despite administration of azithromycin and chest tube drain-
age. A chest CT performed 8 months after this episode
revealed persistent atelectasis of the left lingular lobe.
Case 3. A previously healthy 6-year-old girl had cough for 4
days and fever for 6 days. She was admitted to a local
hospital. On admission, the child was acutely ill with cardio-
pulmonary distress. Body temperature was 39°C, pulse rate
120 beats/min and respiratory rate 50/min. There were rales FIGURE 3. Contrast-enhanced CT shows consolidation of the
and rhonchi in both lung fields. Decreased breath sounds and right lower lobe with patent central bronchus and multiple
friction rubs were noted over the right lung field. A chest abscesses.

© 2004 Lippincott Williams & Wilkins 565

Wang et al. The Pediatric Infectious Disease Journal • Volume 23, Number 6, June 2004

viruses were negative. She was referred to our hospital for C-reactive protein concentration was 11.7 mg/dl. Ampicillin-
further evaluation. A repeated CT of the chest revealed sulbactam was prescribed but the fever persisted. A chest CT
consolidation in the right lung with multiple abscess forma- showed consolidation in the right lower lobe with low density
tion and a moderate amount of right pleural effusion. A lung areas in the central part. Minimal parapneumonic effusion
biopsy with culture was performed, but no bacteria, Myco- was detected; therefore thoracocentesis was not performed.
bacterium tuberculosis, fungi or virus were isolated. The cold The antibiotic was changed to erythromycin 40 mg/kg/day
hemagglutinin titer was 1/128, and the complement fixation after 4 days of treatment with ampicillin-sulbactam. Fever
titer for M. pneumoniae was 1/1280. Antibiotics were dis- subsided 10 days after initiation of erythromycin. The Myco-
continued and substituted with erythromycin (40 mg/kg/day) plasma complement fixation antibody titer was lower than
for 3 weeks. The fever subsided 3 days after the initiation of 1/40 initially and increased to 1/1280 12 days later. The
erythromycin. Two months later, the cold hemagglutinin titer pneumonia resolved gradually without complications.
was 1/8, and the complement fixation titer for M. pneumoniae
was 1/160. Follow-up chest radiograph showed complete DISCUSSION
resolution of the abscess and pleural effusion. M. pneumoniae, a common cause of community-ac-
Case 4. This 4-year-old boy had cough and rhinorrhea for 10 quired pneumonia, has a favorable prognosis and is self-
days and fever for 3 days. Cold sweating and shortness of limited in most cases. The radiographic presentations are
breath were reported. Chest auscultation revealed rhonchi nonspecific, consisting of lobar consolidation, patchy infiltra-
bilaterally and decreased breath sounds over the right lung tion or interstitial infiltrates.4 Parapneumonic effusion occurs
field. A chest roentgenogram showed total consolidation of in 5–20% of M. pneumoniae pneumonia.5 The amount of
the right side lung with pleural effusion. The C-reactive effusion is usually scant and self-limited. Six cases of necro-
protein concentration was 29 mg/dl. A chest CT showed total tizing pneumonitis have been previously reported in the
consolidation of the right lung field with pleural effusion and English language literature.3,6 –9
central necrosis in the right middle lobe (Fig. 4). Diagnostic If protracted courses of fever or worsening respiratory
thoracocentesis and drainage were performed. The Myco- exertion occur in patients with M. pneumoniae pneumonia,
plasma complement fixation antibody titer was 1/1280 at the possibility of complicated parapneumonic effusion or
admission. Azithromycin 12 mg/kg/day was prescribed for 5 necrotizing pneumonitis should be considered. Performance
days. The aspartate aminotransferase was 65 IU/l, and the of further imaging studies such as computerized tomography
alanine aminotransferase was 232 IU/l on the 7th day after is indicated to detect the low density change that cannot be
admission. Fever abated in 10 days. Follow-up chest radio- differentiated on plain films in lobes with total consolidation.
graph showed total resolution of the lung without sequelae. In contrast to the generally held belief that pleural effusion
Case 5. This 3-year-old girl had spiking fever and productive associated with M. pneumoniae infection is small and self-
cough for 3 days. At admission examination, she had dyspnea limited, large pleural effusions requiring chest tube insertion
and decreased breath sounds in the right lung. A chest were present in 4 of our patients. The protein content in
roentgenogram disclosed patchy density over the right lower pleural fluid was high, but the glucose concentration was not
lung field. The laboratory data are shown in Table 1. The as low as that found in bacterial empyema. Predominance of
lymphocytes was present in 3 of the 4 patients. Chest tube
drainage was necessary for a median duration of 5.5 days
(range, 2 to 9 days). All of our patients had leukocytosis in
the peripheral blood with predominance of neutrophils. Four
of the 5 patients had C-reactive protein values higher than 25
mg/dl, suggesting bacterial pneumonia. Thrombocytopenia
was noted in 3 patients at admission. Four patients were
anemic but the cause of anemia was not investigated. Two
patients initially received ␤-lactam antibiotics that are not
active against M. pneumoniae, and fever persisted. Diagnosis
of M. pneumoniae infection was established in the other 3
patients by the absence of bacterial, viral and fungal organ-
isms in pleural fluid and blood and elevated Mycoplasma
complement fixation titers. Fever and respiratory distress
persisted after treatment with macrolides. The median total
days of fever was 15 days in the 5 patients, and fever
FIGURE 4. Computed tomography. Total consolidation of the persisted for a median of 10 days after administration of
right lower lobe with multiloculated abscesses on chest. macrolide and adequate chest tube drainage. The prolonged

566 © 2004 Lippincott Williams & Wilkins

The Pediatric Infectious Disease Journal • Volume 23, Number 6, June 2004 Mycoplasma Necrotizing Pneumonitis

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© 2004 Lippincott Williams & Wilkins 567