Mycoplasma pneumoniae pneumonia in children: Clinical characteristics and risk factors of refractory pneumonia by age

Hyung Young Kim; Hee Ju Park

doi:10.4168/aard.2018.6.6.295

Journal List > Allergy Asthma Respir Dis > v.6(Suppl 1) > 1108838

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Kim and Park: Mycoplasma pneumoniae pneumonia in children: Clinical characteristics and risk factors of refractory pneumonia by age

Original Article

Allergy Asthma Respir Dis 2018;6(6):295-302.

Published online: 5 November 2018

DOI: https://doi.org/10.4168/aard.2018.6.6.295

Mycoplasma pneumoniae pneumonia in children: Clinical characteristics and risk factors of refractory pneumonia by age

Hyung Young Kim^1,², Hee Ju Park¹

¹Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea

²Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea

Correspondence to: Hee Ju Park https://orcid.org/0000-0002-2782-3918 Department of Pediatrics, Pusan National University Children's Hospital, 20 Geumo-ro, Meulgeum-eup, Yangsan 50612, Korea Tel: +82-55-360-2180, Fax: +82-55-360-2181, E-mail: phj7294@hanmail.net

• This work was supported by Research Institute for Convergence of Biomedical Science and Technology Grant (30-2015-020), Pusan National University Yangsan Hospital.

Received 19 July 20181 October 2018 Accepted 1 October 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

It is thought that Mycoplasma pneumoniae infection is more prevalent and causes more severe pneumonia in school-age children and young adults than in preschool children; however, recent studies suggest that the infection may be underdiagnosed and more severe in preschool children. This study investigated the clinical characteristics of Mycoplasma pneumoniae pneumonia (MPP) and the risk factors of refractory MPP (RMPP) by age.

Methods

We retrospectively reviewed the medical records of 353 children admitted due to MPP from January 2015 to December 2016. Demographics, clinical information, laboratory data and radiological findings were collected from all patients in this study. The patients were divided into 2 groups by the age of 6 years. Also, both preschool (<6 years old) and school-age (≥6 years old) children were divided into RMPP and non-RMPP patients.

Results

Total febrile days, febrile days before admission and the duration of macrolide antibiotic therapy were significantly longer in school-age children than in preschool children. School-age children had significantly greater risk of lobar consolidation (P=0.036), pleural effusion (P =0.001) and extrapulmonary complications (P =0.019). Necrotizing pneumonia and bronchiolitis obliterans tended to occur more frequently in preschool children than in school-age children. In both preschool and school-age children, lactate dehydrogenase (LDH) levels were significantly higher in RMPP patients than in non-RMPP patients. In preschool children, LDH >722 IU/L (odds ratio [OR], 3.02; 95% confidence interval [CI], 1.44–6.50) and ferritin >177 ng/mL (OR, 5.38; 95% CI, 1.61–19.49) were significant risk factors for RMPP, while LDH >645 IU/L (OR, 4.12; 95% CI, 1.64–10.97) and ferritin >166 ng/mL (OR, 5.51; 95% CI, 1.59–22.32) were so in school-age children.

Conclusion

Clinical features of MPP were significantly different between preschool and school-age children. LDH and ferritin may be significant factors of RMPP in preschool and school-age children.

Keywords: Mycoplasma pneumoniae, Child, Lactate dehydrogenase, Ferritin

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Fig. 1.

Receiver operator characteristic curves for differentiating RMPP from non-RMPP according to age. (A) Patients <6 years old. (B) Patients ≥6 years old. RMPP, refractory Mycoplasma pneumoniae pneumonia; LDH, lactate dehydrogenase; IL, interleukin.

Fig. 2.

Odds ratio for RMPP according to age. RMPP, refractory Mycoplasma pneumoniae pneumonia; LDH, lactate dehydrogenase. Adjusted for febrile days before admission, sex, year, and season. ∗ P<0.05. ∗∗ P<0.01.

Table 1.

Subject characteristics (n=353)

Characteristic	Value
Sex, male:female	173:180
Age (yr)	5.5±3.7
Age group (yr)
<6	229 (64.9)
≥6	124 (35.1)
Year
2015	173 (49.0)
2016	180 (51.0)
Season
Spring (Mar–May)	39 (11.0)
Summer (Jun–Aug)	63 (17.8)
Autumn (Sep–Nov)	153 (43.3)
Winter (Dec–Feb)	98 (27.8)

Values are presented as mean±standard deviation or number (%).

Table 2.

Clinical characteristics according to age

Characteristic	<6 Years (n=229)	≥6 Years (n=124)	P-value
Sex, male:female	120:109	53:71	0.218
Durations (day)
Hospitalization	7 (5–9)	7 (5–9.5)	0.412
Total febrile days	7 (4–9)	9 (6–11)	<0.001
Febrile days before admission	1 (0–6)	6 (0–9)	<0.001
Febrile days after admission	3 (1–5)	2 (1–5)	0.293
Febrile days before initiation of macrolides	5 (3–7)	6 (4–8)	0.001
Febrile days after initiation of macrolides	2 (1–6)	3 (1–6.5)	0.337
Febrile days before initiation of steroid	8 (7–11)	10.5 (7.5–12)	0.124
Febrile days after initiation of steroid	1 (0–2)	1 (1–1)	0.697
Febrile days before identification of lobar pneumonia	6 (5–9)	8 (6–10)	0.170
Febrile days before identification of pleural effusion	7 (6–8.5)	7.5 (6–9.5)	0.549
Radiologic findings
Lobar consolidation	59 (25.8)	46 (37.1)	0.036
Pleural effusion	27 (11.8)	32 (25.8)	0.001
Pulmonary complications
Necrotizing pneumonia	5 (2.2)	0 (0)	0.253
Bronchiectasis	2 (0.9)	1 (0.8)	0.833
Bronchiolitis obliterans	6 (2.6)	0 (0)	0.192
Extrapulmonary complications	5 (2.2)	10 (8.1)	0.019
RMPP	74 (34.7)	48 (40.0)	0.402
Treatment
Length of macrolides (d)	14 (10–15)	14 (12–15)	0.281
Steroid	59 (25.8)	32 (25.8)	1.000
Oxygen supplement	31 (13.5)	15 (12.1)	0.827
Intensive care unit	4 (1.7)	2 (1.6)	1.000

Values are presented as median (interquartile range) or number (%).

RMPP, refractory Mycoplasma pneumoniae pneumonia.

Table 3.

Laboratory values between non-RMPP and RMPP according to age

Variable	<6 Years (n=216)			≥6 Years (n=117)
Variable	Non-RMPP (n=138)	RMPP (n=64)	P-value	Non-RMPP (n=72)	RMPP (n=41)	P-value
White blood cell (×10⁹	⁹/L) 10.01 (7.45–14.83)	9.60 (7.01–13.41)	0.733	8.00 (6.20–10.21)	6.95 (5.47–11.11)	0.579
Neutrophils (%)	58.6 (49.0–68.4)	60.6 (47.4–73.2)	0.841	68.8 (62.0–76.2)	65.5 (60.0–74.4)	0.463
ESR (mm/hr)	24.0 (13.5–35.0)	26.0 (13.5–43.0)	0.364	28.0 (22.0–43.5)	28.0 (20.0–44.0)	0.633
LDH (IU/L)	685.0 (579.0–847.0)	907.0 (706.5–1,270.5)	0.023	589.5 (507.0–711.0)	759.0 (614.0–979.0)	0.002
CRP (mg/dL)	2.4 (1.1–4.2)	2.5 (0.8–6.5)	0.141	3.2 (1.7–6.1)	2.9 (1.5–7.8)	0.508
Ferritin (ng/mL)	103.0 (71.5–133.5)	141.0 (97.0–348.0)	0.040	135.0 (97.0–195.0)	183.0 (116.0–304.0)	0.023
	Non-RMPP (n=17)	RMPP (n=19)	P-value	Non-RMPP (n=13)	RMPP (n=14)	P-value
IL-4 (pg/mL)	45.0 (38.0–45.0)	56.7 (47.3–68.6)	0.400	48.0 (45.0–51.1)	23.2 (20.6–29.7)	0.004
IL-2Rα (pg/mL)	2,533.5 (2,097.2–3,755.2)	3,519.6 (2,263.2–4,297.1)	0.749	1,958.7 (1,737.9–2,585.0)	3,096.7 (2,056.5–3,857.0)	0.252
IL-10 (pg/mL)	7.7 (2.6–9.4)	15.0 (4.0–22.1)	0.429	4.6 (3.0–12.7)	13.6 (9.8–23.9)	0.209
IL-17A (pg/mL)	4.9 (4.6–5.3)	4.6 (3.9–4.6)	0.274	4.6 (3.9–4.6)	4.6 (3.9–4.8)	0.435
IL-18 (pg/mL)	620.9 (470.6–794.9)	1,051.8 (519.4–1,234.3)	0.363	552.8 (452.3–780.6)	872.1 (596.7–1167.0)	0.589
IFN-γ (pg/mL)	37.0 (23.4–69.9)	79.7 (26.8–198.7)	0.183	37.0 (19.3–108.2)	23.4 (9.2–60.0)	0.181
CXCL9 (pg/mL)	553.6 (316.0–903.5)	646.1 (406.9–1,031.1)	0.310	748.6 (553.6–1,212.0)	1,248.5 (748.6–1,504.7)	0.472
CXCL10 (pg/mL)	52.9 (35.3–145.2)	137.0 (34.7–388.1)	0.099	78.0 (58.2–168.1)	98.6 (59.3–303.5)	0.433

Values are presented as median (interquartile range).

RMPP, refractory Mycoplasma pneumoniae pneumonia; ESR, erythrocyte sedimentation rate; LDH, lactate dehydrogenase; CRP, C-reactive protein; IL, interleukin; IFN, interferon; CXCL, C-X-C motif ligand.

All data were adjusted by febrile days before admission.

Table 4.

Receiver operating characteristic curve analysis for predicting RMPP according to age

Variable	Cutoff value	AUC (95% CI)	Sensitivity (%)	Specificity (%)	PPV (%)	NPV (%)	P-value
LDH (IU/L)
<6 yr	722	0.697 (0.617–0.778)	74.6	63.0	15.5	52.0	<0.001
≥6 yr	645	0.708 (0.605–0.811)	70.7	66.7	20.0	45.3	<0.001
Ferritin (ng/mL)
<6 yr	177	0.690 (0.597–0.784)	42.0	91.6	27.6	25.0	<0.001
≥6 yr	166	0.655 (0.527–0.784)	62.1	71.7	22.4	45.5	<0.001
IL-17A (pg/mL)
<6 yr	5.3	0.688 (0.524–0.852)	85.7	47.4	25.0	35.7	<0.001

RMPP, refractory Mycoplasma pneumoniae pneumonia; AUC, area under the ROC curve; CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value; LDH, lactate dehydrogenase; IL, interleukin.

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