title: Mycoplasma-induced minimally conscious state.
abstract: Mycoplasma pneumoniae (M. pneumoniae) frequently causes community-acquired respiratory tract infection and often presents as atypical pneumonia. Following airborne infection and a long incubation period, affected patients mostly suffer from mild or even asymptomatic and self-limiting disease. In particular in school-aged children, M. pneumoniae is associated with a wide range of extrapulmonary manifestations including central nervous system (CNS) disease. In contrast to children, severe CNS manifestations are rarely observed in adults. We report a case of a 37 year-old previously healthy immunocompetent adult with fulminant M. pneumoniae-induced progressive encephalomyelitis who was initially able to walk to the emergency department. A few hours later, she required controlled mechanical ventilation for ascending transverse spinal cord syndrome, including complete lower extremity paraplegia. Severe M. pneumoniae-induced encephalomyelitis was postulated, and antimicrobial, anti-inflammatory and immunosuppressive therapy was applied on the intensive care unit. Despite early and targeted therapy using four different immunosuppressive strategies, clinical success was limited. In our patient, locked-in syndrome developed followed by persistent minimally conscious state. The neurological status was unchanged until day 230 of follow-up. Our case underlines that severe M. pneumoniae- related encephalomyelitis must not only be considered in children, but also in adults. Moreover, it can be fulminant and fatal in adults. Our case enhances the debate for an optimal antimicrobial agent with activity beyond the blood-brain barrier. Furthermore, it may underline the difficulty in clinical decision making regarding early antimicrobial treatment in M. pneumoniae disease, which is commonly self-limited.
authors.affiliation: Department of Neurology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland.
authors.forename: Thomas
authors.initials: T
authors.lastname: Horvath
authors.affiliation: Department of Neurology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland.
authors.forename: Urs
authors.initials: U
authors.lastname: Fischer
authors.affiliation: Department of Intensive Care Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland.
authors.forename: Lionel
authors.initials: L
authors.lastname: Müller
authors.affiliation: Department of Pulmonary Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Ott
authors.affiliation: Department of Neurology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland.
authors.forename: Claudio L
authors.initials: CL
authors.lastname: Bassetti
authors.affiliation: Department of Diagnostic and Interventional Neuroradiology, Bern University Hospital, 3010 Bern, Switzerland.
authors.forename: Roland
authors.initials: R
authors.lastname: Wiest
authors.affiliation: Department of Infectious Diseases, Inselspital, Bern University Hospital, 3010 Bern, Switzerland.
authors.forename: Parham
authors.initials: P
authors.lastname: Sendi
authors.affiliation: Department of Intensive Care Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland.
authors.forename: Joerg C
authors.initials: JC
authors.lastname: Schefold
keywords: Atypical pneumonia; Coma; Encephalitis; ICU; Mycoplasma pneumoniae; Myelitis