Buehler, R.

Gebhardt, A.

Humpert, S.

Kaelin-Lang, A.

Mattle, H.

Sellner, J.

Tewald, F.

Wiest, R.

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J Neurol (2008) 255:1268–1269DOI 10.1007/s00415-008-0870-2 LETTER TO THE EDITORSJON 2870On the other hand, several neu-rological manifestations have been described following Mycoplasmapneumonia [4, 5] infection, a com-mon bacterium of the respiratory tract, including acute transversemyelitis (ATM) [11]. Here we present a patient with typical NMO after M. pneumoniainfection that may represent an underestimated etiology for NMO. A previously healthy 32-year-old woman developed fever and a non-productive cough. A chest x-ray showed an infiltrate in the right in-ferior lobe. Respiratory symptomsimproved with erythromycin treat-ment. Ten days later she experi-enced paresthesia and weakness inboth legs, urinary retention and was admitted to our department. On neurological examinationshe was alert. Cranial nerves were normal, but there was tetraparesiswith tetrahyperreflexia and hyp-aesthesia with a sensory level at the4th thoracic level. No signs of me-ningism were present. Sphincter tone was reduced on rectal exami-nation. The night after admission, the patient had to be transferred to our intensive care unit because of respiratory failure requiring intu-bation. MRI investigation revealed a severe myelitis (Fig.1A and B).CSF investigation showed 15white blood cells per μL, 37 % poly-morphonuclear neutrophils. There was no quantitative intrathecal immunoglobulin production. Serologic examinations showeda highly positive complement fixa-tion test (CFT) to M. pneumonia(1:5120). An indirect immunofluo-rescence assay was used to search for M. pneumonia antibodies in CSF and serum. This investigationrevealed an elevated titer of IgG antibodies specific to M. pneumo-nia in the CSF. In combination withan antibody specificity index of 9.5 these results indicate an intrathecal production of IgG antibodies spe-cific to M. pneumonia. Neither in Andreas GebhardtRobert BuehlerRoland WiestFriedemann TewaldJohann SellnerSebastian HumpertHeinrich P. MattleAlain Kaelin-LangMycoplasma pneumoniaas a cause of neuromyeli-tis optica?Received: 8 July 2007Received in revised form:11 December 2007Accepted: 7 January 2008Published online: 23 June 2008Sirs: Until recently neuromyelitisoptica (NMO) was regarded as a severe form of multiple sclerosis(MS). But characteristic serologicand neuroradiological findings andparticularly the discovery of thespecific NMO antibody by Lennon and colleagues [8] indicate that NMO is an autoimmune diseasedifferent from MS. In a few patients, typical NMO isassociated with viral infection like HIV [3], Dengue fever [10], vari-cella infection [1], infectiousmononucleosis [12] and hepatitis A virus [6]. The only bacterial agent that has been associated with NMOis Mycobacterium tuberculosis [2].CSF nor in serum were there signs of another acute infection or auto-immune disorder. NMO-IgG anti-aquaporin-4 antibodies [8] werenegative. Within 4 days the tetrapa-resis progressed to tetraplegia. Sensory level of hypesthesia moved up to C4 and bilateral blindnessoccurred. An immunosuppressive therapy with methylprednisoloneand later with plasma exchange and mitoxantron was initiated inaddition to the initial antibiotics therapy. Blindness resolved slowly within the following months. After 1 year, the patient had regainedalmost full function of both upperextremities. Visual function was normal, but she was still paraspas-tic and -plegic. CFT to M. pneumo-nia had decreased to 1:120 and spi-nal MRI revealed an atrophy (Fig.1C).In this case, the development of symptoms after pneumonia andassociated increase of M. pneumo-nia antibody titres both in serumand CSF strongly suggests that the mycoplasma infection is involvedin this NMO syndrome.Several neurological complica-tions including ADEM and ATMhave been described after M. pneu-monia infection [5, 9]. Both directCNS infection and an autoimmune mechanism triggered by M. pneu-monia are possible. Since direct PCR evidence for M. pneumonia isonly seldom found in CSF [11], it is often difficult to differentiate be-tween both possibilities [5]. The clinical syndrome with bilateral optic neuritis and longitudinally extensive myelitis is typical for NMO and, to the best of our knowl-edge, has not been reported to datein association with M. pneumoniainfection. Overall, an autoimmune parainfectious pathogenesis seemsmore likely than a direct infectionsince the symptoms started lateafter the pneumonia, progressed inspite of an adequate antibiotictreatment, and since CSF analysisA. Gebhardt · R. Buehler · J. Sellner ·S. Humpert · H. P. Mattle · A. Kaelin-Lang (,)Dept. of NeurologyUniversity of BernInselspital3010 Bern, SwitzerlandFax: +41-31/632-2752E-Mail: alain.kaelin@dkf.unibe.chR. WiestDept. of NeuroradiologyUniversity of BernInselspital3010 Bern, SwitzerlandF. TewaldLabor Enders and PartnersRosenbergstrasse 8570193 Stuttgart, Germany1269revealed only weak inflammatory signs in spite of a strong anti-mycoplasma antibodies titre. In this case, the recently publishedrevised diagnostic criteria forNMO are fulfilled [13] even though the anti-aquaporin-4 antibodies[7], which have a 90 % specificity for NMO, were not detected in the CSF or blood. We postulate that this caserepresents an anti-aquaporin-4antibody negative NMO syndrome following M. pneumonia infection. We propose that in patients with NMO syndrome, especially caseswith rapid symptom onset, a com-prehensive search for possible infectious etiologies including M. pneumonia infection should beperformed. References1. Ahasan HA, Rafiqueuddin AK, Chowd-hury MA, Azhar MA, Kabir F (1994)Neuromyelitis optica (Devic’s disease)following chicken pox. Trop 24(2):757–7562. Barbizet J, Degos JD, Meyrignac C (1980) Acute neuromyelitis optica and acute pulmonary tuberculosis. Rev Neurol (Paris) 136(4):303–3093. Blanche P, Diaz E, Gombert B, Sicard D, Rivoal O, Brezin A (2000) Devic’s neu-romyelitis optica and HIV-1 infection JNeurol Neurosurg Psychiatry 68(6):795–7964. Behan PO, Feldman RG, Segerra JM, Draper IT (1986) Neurological aspectsof mycoplasmal infection. Acta NeurolScand 74(4):314–3225. Guleria R, Nisar N, Chawla TC, Biswas NR (2005) Mycoplasma pneumoniae and central nervous system complica-tions: a review. J Lab Clin Med 146(2):55–636. Jouhadi Z, Ouazzani I, Abid A, El Moutawakil B, Rafai MA, Slassi I (2004)Devic’s optic neuromyelitis and viral hepatitis type A. A paediatric case report. Rev Neurol (Paris) 160(12):1198–12027. Lennon VA, Kryzer TJ, Pittock SJ, Verk-man AS, Hinson SR (2005) IgG marker of optic-spinal multiple sclerosis bindsto the aquaporin-4 water channel. J Exp Med 15; 202(4):473–4778. Lennon VA, Wingerchuk DM, Kryzer TJ, Pittock SJ, Lucchinetti CF, FujiharaK, Nakashima I, Weinshenker BG(2004) A serum autoantibody markerof neuromyelitis optica: distinction from multiple sclerosis. Lancet 11–17;364(9451):2106–21129. Menge T, Hemmer B, Nessler S, WiendlH, Neuhaus O, Hartung HP, Kieseier BC, Stuve O (2005) Acute disseminated encephalomyelitis: an update. Arch Neurol 62(11):1673–168010. Miranda de Sousa A, Puccioni-SohlerM, Dias Borges A, Fernandes Adorno L, Papais Alvarenga M, Papais AlvarengaRM (2006) Post-dengue neuromyelitis optica: case report of a Japanese-descendent Brazilian child. J Infect Chemother 12(6):396–39811. Tsiodras S, Kelesidis I, Kelesidis T, Stamboulis E, Giamarellou H (2005)Central nervous system manifestations of Mycoplasma pneumoniae infec-tions. J Infect 51(5):343–354 12. Williamson PM (1975) Neuromyelitis optica following infectious mononu-cleosis. Proc Aust Assoc Neurol 12:153–155 13. Wingerchuk DM, Lennon VA, Pittock SJ, Lucchinetti CF, Weinshenker BG(2006) Revised diagnostic criteria forneuromyelitis optica. Neurology 23;66(10):1485–1489Fig. 1 Spinal MRI. A Sagittal T2-weighted TSE images reveal progressive T2-hyperintense and progressiveswelling of the spinal cord at the level of C2-Th1 and Th4-Th9 16 days after symptoms onset. B T1-weighted SEimages show hemorrhagic transformation at the level of Th5–Th9. C Follow-up examination after 10 monthsreveal severe atrophy of the thoracic cord

Mycoplasma pneumonia as a cause of neuromyelitis optica?

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Mycoplasma pneumonia as a cause of neuromyelitis optica?

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