eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Mycoplasma Infections

Author: Archana Chatterjee, MD, PhD, Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital
Coauthor(s): Catherine O'Keefe, DNP, APRN, Assistant Professor of Nursing and Pediatric Nurse Practitioner, Pediatric Infectious Diseases, Creighton University Medical Center
Contributor Information and Disclosures

Updated: Aug 10, 2009

Introduction

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 Media file 1).1

General characteristics of <em>Mycoplasma</em> sp...

General characteristics of Mycoplasma species.

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General characteristics of <em>Mycoplasma</em> sp...

General characteristics of Mycoplasma species.



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 of the respiratory and genital tracts. A unique group of membrane proteins allow this adherence.2  The attachment site, or receptor, is a complex carbohydrate structurally akin to antigen I of RBCs. 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.

Mycoplasma pneumoniae is one of the few Mycoplasma species that causes human disease.3 Most M pneumoniae –associated illnesses are confined to the respiratory tract; however, M pneumoniae respiratory infections are also associated with various extrapulmonary manifestations.4,5,6,7 The pathogenesis of extrapulmonary complications is unknown but is thought to be an immunomediated mechanism.8  Systemic spread of the bacterium is rare. Genital mycoplasmal organisms are associated with numerous genitourinary tract and reproductive diseases but also can cause infections at other sites.1

Genital mycoplasmal organisms (eg, Mycoplasma hominis, Mycoplasma fermentans, Mycoplasma genitalium, Ureaplasma species) are sexually transmitted. Colonization rates for M hominis and Ureaplasma species are 20-50% and 40-50%, respectively. These organisms are associated with numerous genitourinary tract and reproductive diseases and have been implicated in preterm labor and bacteremia in very preterm newborn infants.9,10,11

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.1

Frequency

United States

The disease is distributed worldwide without regard to season.3 Atypical organisms such as M pneumoniae are implicated in up to 40% of cases of community-acquired pneumonia.12,13 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 may be much higher because most mild-to-moderate cases are treated empirically.

International

A recent study focused on the epidemiological and clinical features of an M pneumoniae outbreak in a kindergarten class in Beijing, China.14 The report determined that the outbreak was caused by poor ventilation in a temporary classroom.

Mortality/Morbidity

Most M pneumoniae infections lead to clinically apparent disease involving the upper respiratory tract; the symptoms include pharyngitis, cough, headache, chills, and myalgias.1 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.1 M pneumoniae has been strongly implicated in the pathogenesis of asthma, leading to acute and chronic wheezing in some individuals.15,16

Precedent M pneumoniae respiratory infections have also been implicated in patients who present with extrapulmonary illness. The most common sites of extrapulmonary manifestations are dermatologic (25%) and CNS (1-10%), although cardiac, musculoskeletal, hematologic, and GI symptoms have also been reported.9,6

Children with compromised immunity, including those with humoral immunodeficiencies, are more likely to experience complications.3,8 In individuals with sickle cell anemia, mycoplasmal infection may be severe, with acute chest syndrome reported.17 Unusually severe M pneumoniae infection has also been reported in children with Down syndrome, especially those with congenital heart disease.1

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.17 Those who develop extremely high cold agglutinin titers may experience digital necrosis.1 Because sickle cell disease and other related hemoglobinopathies are most common among blacks, severe complications of mycoplasmal infections also occur most frequently in this group of patients.

Genital Mycoplasma species have been isolated more frequently from black men and women than from white men and women.18 Ureaplasma species are found 4 times more often than M 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.8

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 respiratory disease and extrapulmonary illness. M pneumoniae infection is common in school-aged children and adolescents, with the highest rate of infection in individuals aged 5-9 years, in whom the tendency is to develop bronchitis and pneumonia.1

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.1 Colonization usually does not persist beyond 2 years.8

Clinical

History

Symptoms of Mycoplasma pneumoniae infection are often nonspecific. The onset is usually insidious, with fever, malaise, headache, and cough. Cough is a hallmark of M pneumoniae infection.9,4,12,13 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 exacerbate chronic obstructive pulmonary disease, and acute asthma may be the first manifestation ofinfection.15,16,19,20,21

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.1,22,23,24,25,26,27,28 Neonates may present with symptoms of cough, meningitis, or brain abscess.29,30

Physical

Patients with M pneumoniae infection usually do not appear ill, and the illness often has been termed walking pneumonia.1,3,4,12,13 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.31 Wheezing can occur, especially in patients with asthma.32 Rarely, fulminant pneumonia with respiratory failure can occur.15,16,18

Physical findings of genital Mycoplasma infection vary depending on the type of infection.33,34 Neonates, especially premature infants, may present with wheezing, retractions, and respiratory failure or signs of meningitis/brain abscess (eg, seizures, lethargy, neurologic deficits).29,30

Extrarespiratory manifestations of M pneumoniae infection include the following:
  • Dermatologic manifestations (most common)4,5
  • Urticarial manifestations
  • Cardiac manifestations
    • Arrhythmia and/or ECG abnormalities (conduction defects)
    • Congestive failure
    • Pericarditis
    • Myocarditis
    • Endocarditis
  • Neurologic manifestations5,7
    • 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 anemia35

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.

More on Mycoplasma Infections

Overview: Mycoplasma Infections
Differential Diagnoses & Workup: Mycoplasma Infections
Treatment & Medication: Mycoplasma Infections
Follow-up: Mycoplasma Infections
Multimedia: Mycoplasma Infections
References
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References

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Further Reading

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Keywords

Mycoplasma infections, walking pneumonia, pneumonia, mycoplasmal pneumonia, Mycoplasma pneumonia, M pneumoniae infection, Mycoplasma pneumoniae, tracheobronchitis, pleural effusion, sickle cell anemia, Down syndrome, respiratory distress, otitis media, asthma, bronchitis, sinusitis, erythematous macular rash, Stevens-Johnson syndrome, erythema nodosum, Raynaud phenomenon, congestive failure, pericarditis, endocarditis, brainstem dysfunction, Guillain-Barré syndrome, hemolytic anemia, treatment, diagnosis

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Contributor Information and Disclosures

Author

Archana Chatterjee, MD, PhD, Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital
Archana Chatterjee, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, International Society for Infectious Diseases, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: GlaxosmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi-Pasteur Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; GlaxoSmithKline Grant/research funds Other; MedImmune  Other; Merck Grant/research funds Other; Novartis Grant/research funds Other; Sanofi-Pasteur Grant/research funds Other

Coauthor(s)

Catherine O'Keefe, DNP, APRN, Assistant Professor of Nursing and Pediatric Nurse Practitioner, Pediatric Infectious Diseases, Creighton University Medical Center
Catherine O'Keefe, DNP, APRN is a member of the following medical societies: American Academy of Nurse Practitioners, National Association of Pediatric Nurse Practitioners, and Nebraska Nurse Practitioners
Disclosure: Nothing to disclose.

Medical Editor

Rosemary Johann-Liang, MD, Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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