Pediatric Mycoplasma pneumoniae Infection Presenting with Acute Cholestatic Hepatitis and Other Extrapulmonary Manifestations in the Absence of Pneumonia

Song, Won Jae; Kang, Ben; Lee, Hwa Pyung; Cho, Joongbum; Lee, Hae Jeong; Choe, Yon Ho

The concurrent symptoms and signs of other extrapulmonary manifestations, such as erythematous maculopapular skin rash, rhabdomyolysis, and initial laboratory exams favoring disseminated intravascular coagulopathy (DIC) in our case further support the assumption that our case may have been related with an indirect-type mechanism rather than a direct type mechanism. Association between M. pneumonia infection and dermatologic manifestations such as erythematous maculopapular eruptions and erythema multiforme are well known [12] , and the molecular mimicry between Mycoplasma P1-adhesin molecule and keratinocyte antigen leading to the generation of cross-reacting antibodies, immune-complex formation, and complement activation have been reported to attribute to the development of Mycoplasma induced rash and mucositis (MIRM) [13] . Rhabdomyolysis is often accompanied by multiple extrapulmonary manifestations in M. pneumoniae infection as in our case [7, 14] , although the exact underlying pathomechanism has not been revealed. Recently, it has been suggested that tumor necrosis factor-alpha may play a role in the pathogenesis of rhabdomyolysis associated with M. pneumoniae infection [15] . The development of DIC in M. pneumoniae infection is related with the vascular occlusion type mechanism in the presence of a systemic hypercoagulable state [7] . Abnormal immune regulation in M. pneumoniae infection has been suggested to activate complements or induce procoagulant mediators attributing to the development of DIC [16] [17] [18] . Therefore, our case may have been related with an indirect-type plus a vascular occlusion type mechanism.