J Chin Med Assoc • April 2009 • Vol 72 • No 4204© 2009 Elsevier. All rights reserved.

Introduction

Viral hepatitis accounts for most cases of acute hepati-tis. Some bacterial infections are often associated withacute hepatitis, such as Salmonella, Rickettsia, Brucellaor Mycoplasma pneumonia. M. pneumonia is a majorcause of respiratory infections in school-aged childrenand young adults.1 Extrapulmonary manifestations of M. pneumonia include the skin, neurologic in-volvement, hematologic complications, myocarditis,pericarditis and cholestatic hepatitis in children.2

M. pneumonia infection in adults usually occurs withoutliver involvement except in some rare cases.3 Here, wepresent a case of acute hepatitis caused by M. pneumoniawithout lung involvement. Reports of M. pneumonia-associated acute hepatitis retrieved from MEDLINEare also reviewed.

Case Report

A 25-year-old woman who worked in an office, andwho had no specific underlying illness, was admitted toour hospital with persistent fever, chills and abdomi-nal pain in the right upper quadrant, all of which had

began 3 days before admission. She had no history ofnausea, vomiting, diarrhea, cough, dysuria, arthralgia,night sweating or body weight loss. Other medicalhistory, travel history and family history were unre-markable. She denied history of exposure to animals.She had been brought to the hospital for treatment ofthe abovementioned symptoms.

On physical examination, the patient was in distress.She had a body temperature of 37.6°C, heart rate of70 beats/min, blood pressure of 130/90 mmHg, res-piratory rate of 20 breaths/min and oxygen satura-tion of 99% under room air. There was no significanticteric sclera or yellowish skin. Neither rhonchi nor raleswere heard over bilateral lung fields. Mild abdominaltenderness was found in the right upper quadrant,and the edge of the liver was felt 2–3 cm below theright costal margin. No lymphadenopathy or spleno-megaly was found. Laboratory work-up demonstrateda white cell count of 4.5 × 103/μL (normal, 4–11 ×103/μL), hemoglobin of 12 g/dL (normal, 11.3–15.3 g/dL), platelet count of 140 × 103/μL (normal,120–320 × 103/μL), blood urea nitrogen of 10mg/dL(normal, 8–20 mg/dL), creatine of 0.8 mg/dL (nor-mal, 0.6–1.2 mg/dL), aspartate aminotransferase(AST) of 380 U/L (normal, 4–44 U/L), alanine

CASE REPORT

Mycoplasma pneumonia-associated Acute Hepatitisin an Adult Patient without Lung Infection

Shou-Wu Lee*, Sheng-Shun Yang, Chi-Sen Chang, Hong-Jeh Yeh, Wai-Keung Chow

Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C.

Mycoplasma pneumonia is a major cause of respiratory infections in school-aged children. Most M. pneumonia infections

in adults involve the respiratory tract. Extrapulmonary manifestations of M. pneumonia infection may be found in the

skin, cardiovascular, neurologic and hematologic systems. Concomitant liver disease is rare in adults. Here, we report an

unusual case of a patient who presented with fever and abdominal pain, but without pulmonary manifestations. The lab-

oratory work-up demonstrated a hepatocellular pattern of acute hepatitis caused by M. pneumonia infection. Symptoms

subsided and laboratory parameters improved with antibiotics treatment. Thus, this case can help raise clinicians’

awareness of the possibility of M. pneumonia infection, with or without lung involvement, as a part of the evaluation of

undetermined hepatitis. [J Chin Med Assoc 2009;72(4):204–206]

Key Words: acute hepatitis, adult, Mycoplasma pneumonia

*Correspondence to: Dr Shou-Wu Lee, Division of Gastroenterology, Department of Internal Medicine,Taichung Veterans General Hospital, 160, Section 3, Chung-Kang Road, Taichung 407, Taiwan, R.O.C.E-mail: ericest@vghtc.gov.tw ● Received: July 18, 2008 ● Accepted: December 15, 2008

J Chin Med Assoc • April 2009 • Vol 72 • No 4 205

Acute hepatitis related to Mycoplasma pneumonia

aminotransferase (ALT) of 273 U/L (normal,8–38 U/L), alkaline phosphatase (ALP) of 79 U/L(normal, 50–190 U/L), total bilirubin of 0.5 (normal,0.1–1.2 mg/dL), and C-reactive protein of 0.9 mg/dL(normal, < 0.5 mg/dL). Prothrombin time was withinnormal limits (10.3 seconds). Chest X-ray showed noactive lesion, and abdominal ultrasound did not revealany specific findings. Abdominal computed tomogra-phy (CT) detected no hepatosplenomegaly. Otherexaminations were negative for HBsAg, HBeAg, anti-HBc IgM, anti-hepatitis C IgG, anti-hepatitis A IgM,antinuclear antibodies (ANA), anti-mitochondrial anti-bodies and anti-smooth muscle antibodies (ASMA).IgM antibodies against Salmonella, Proteus, Epstein-Barr virus (EBV) and cytomegalovirus (CMV) werenegative. Anti-M. pneumonia IgM antibodies (1:320)and cold agglutinin test (1:512) were positive. Liverbiopsy was not performed because of the patient’srefusal.

Medication with intravenous levofloxacin wasadapted initially to cover broadspectrum organisms,followed by oral doxycycline 5 days later after thediagnosis of M. pneumonia infection was confirmed,and symptomatic recovery occurred on the 7th day ofhospitalization. Liver function parameters showedthat AST and ALT reached peak levels on the 2nd dayof hospitalization (584 U/L and 777 U/L, respec-tively), and gradually returned to normal 1 monthafter the onset of symptoms (Figure 1). There was nohyperbilirubinemia, but anti-M. pneumonia IgM waspositive during hospitalization. No anti-M. pneumo-niae IgG was detected during the admission period.

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J Chin Med Assoc • April 2009 • Vol 72 • No 4206

S.W. Lee, et al

The patient was later discharged from hospital andreceived clinical follow-up.

Discussion

Most M. pneumonia infections in adults involve therespiratory tract, and symptoms range from nonpro-ductive cough to severe pneumonia.4 Extrapulmonarymanifestations of M. pneumonia infection may befound in the skin, and cardiovascular, neurologic andhematologic systems.5 Skin lesions include macu-lopapular rashes, erythema multiforme minor, andStevens-Johnson syndrome. Cardiovascular involve-ment includes myocarditis, pericarditis and rheumaticfever-like syndrome. Neurologic complications includemeningoencephalitis, aseptic meningitis, cerebellarataxia and Guillain-Barre syndrome. Hematologic in-volvement includes hemolysis with positive Coombs’test and reticulocytosis. The immune-mediated dam-age by cross-reactive anti-M. pneumonia antibodies isthought to be responsible for most of the extrapul-monary manifestations.2

Liver disease is rare and not considered as an extra-pulmonary manifestation of infection with M. pneu-monia in adults.3 The characteristic findings of patientswith M. pneumonia-associated acute hepatitis withoutlung infection are fever, elevated liver function test,positive IgM serology against M. pneumonia followedby IgG seroconversion, with resolution by antibioticsand exclusion of other possible etiologies. Liver biopsyin these patients is usually nonspecific,6 and it mightnot be necessary to confirm diagnosis.

A few cases of M. pneumonia-associated acute hepa-titis from MEDLINE are summarized in Table 1.2,3,7

Acute hepatitis due to M. pneumonia without lunginfection has been largely documented in childrenwith cholesteric pattern. However, although this factremains controversial, adults with M. pneumonia in-fection have demonstrated a hepatocellular pattern ofliver enzymes without jaundice. The liver functionparameters of our patient had similar characteristics,

suggesting differences among adults and childreninfected with M. pneumonia.3

Consistent with the findings in previous studies,2,3,7

our patient’s fever subsided 1 week after institution ofantibiotics. However, the persistent liver enzyme ele-vation may have been mediated by immunologicmechanisms such as cross-reactive antibodies inducedby M. pneumonia interacting with sialo-oligosaccharideson hepatic cells.4 There is little evidence to indicatedirect invasion of M. pneumonia.3

In conclusion, we have reported an unusual caseof a patient who presented with fever and abdominalpain. Laboratory work-up demonstrated a hepatocel-lular pattern of acute hepatitis caused by M. pneumoniainfection. Symptoms subsided and laboratory param-eters improved under antibiotics administration.Thus, this case can help raise clinicians’ awareness ofthe possibility of M. pneumonia infection, with orwithout lung involvement, as a part of the evaluationof undetermined hepatitis.

References

1. Feigin ED, Cherry JD, eds. Textbook of Pediatric InfectiousDisease, 3rd edition. Philadelphia: WB Saunders, 1992:1866–76.

2. Arav-Boger R, Assia A, Spirer Z, Bujanover Y, Reif S. Cholestatichepatitis as a main manifestation of Mycoplasma pneumoniaeinfection. J Pediatr Gastroenterol Nutr 1995;21:459–60.

3. Romero-Gomez M, Otero MA, Sanchez-Munoz D, Ramirez-Aros M, Larraona JL, Suarez-Garcia E, Vargas-Romero J. Acutehepatitis due to Mycoplasma pneumoniae infection withoutlung involvement in adult patients. J Hepatol 2006;44:827–8.

4. Grullich C, Baumert TF, Blum H. Acute Mycoplasma pneumo-niae infection presenting as cholestatic hepatitis. J Clin Microbiol2003;41:514–5.

5. Chen CJ, Juan CJ, Hsu ML, Lai YS, Lin SP, Cheng SN.Mycoplasma pneumoniae infection presenting as neutropenia,thrombocytopenia, and acute hepatitis in a child. J MicrobiolImmunol Infect 2004;37:128–30.

6. Murray HW, Masur H, Senterfit LB, Roberts RB. The proteanmanifestations of Mycoplasma pneumoniae infection in adults.Am J Med 1975;58:229–42.

7. Narita M, Yamada S, Nakayama T, Sawada H, Nakajima M,Sageshima S. Two cases of lymphadenopathy with liver dysfunc-tion due to Mycoplasma pneumoniae infection with mycoplasmalbacteraemia without pneumonia. J Infect 2001;42:154–6.