Abstract Introduction Mycoplasma pneumoniae is a bacterial respiratory pathogen most commonly seen in children between the ages of 5 and 17 years old, and commonly causes symptoms such as fever, cough, sore throat, and congestion. The illness course is typically thought of as a mild infection with gradual symptom onset (hence the colloquial term, “walking pneumonia”), although severe features can be common in children. In this case, a critically ill patient with respiratory failure that may have been explained by Mycoplasma pneumoniae illustrates the infection’s diverse possible clinical presentations, and raises the question: should pediatric hospitals more frequently offer empiric antimicrobial coverage of atypical pathogens to patients with pneumonia? Case A healthy 10-year-old female presented to the Emergency Department (ED) for increased work of breathing after several days of cough and fever. In the ED, she was afebrile, but tachycardic, tachypneic, wheezing, and hypoxic. Her respiratory symptoms initially improved with bronchodilator therapy with subsequent regression in clinical status requiring supplemental oxygen. An X-ray demonstrated a right lower lobe pneumonia and a small pleural effusion. Ampicillin therapy was initiated to treat presumed community acquired pneumonia (CAP), but her clinical status continued to decompensate and she subsequently required bilevel positive airway pressure (BIPAP). She was treated with systemic steroids and continued standing bronchodilators in the intensive care unit (ICU). Her white blood cell (WBC) count, absolute neutrophil count (ANC), and C-reactive protein (CRP) were within normal limits, and an initial respiratory pathogen panel (RPP) was negative. She was breathing room air by day 3 of her hospitalization, by which point a repeat RPP was positive for Mycoplasma pneumoniae, and she was started on azithromycin therapy. Discussion Mycoplasma pneumoniae infection is classically characterized by an indolent symptom onset with interstitial infiltrates seen on chest imaging. Severe manifestations with focal or multifocal radiographic findings are, however, common. It is challenging to ascertain whether this patient had CAP, Mycoplasma pneumoniae, or both simultaneously. Unremarkable lab results in a patient with first lifetime bronchodilator-responsive wheeze may be more consistent with Mycoplasma pneumoniae. There are high false negative rates for Mycoplasma pneumoniae on RPP; this may have led the patient’s providers neglecting to treat atypical pneumonia pathogens and could have contributed to her clinical worsening. Routinely treating for both CAP and Mycoplasma pneumoniae in the event of diagnostic uncertainty may improve patient outcomes. This abstract is funded by: None
Milki et al. (Fri,) studied this question.