Case report and literature study on the resolution of Neonatal Mycoplasma hominis meningitis with non-specific therapy

doi:10.21203/rs.3.rs-4956465/v1

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Case report and literature study on the resolution of Neonatal Mycoplasma hominis meningitis with non-specific therapy

https://doi.org/10.21203/rs.3.rs-4956465/v1

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Background

Mycoplasma hominis primarily inhabits in the human urogenital tract. Pregnant women can transmit it to their newborns during delivery, posing potential risks to both full-term and preterm infants. In severe cases, it can even cause neonatal Mycoplasma hominis meningitis.

Case presentation:

We reported a case of Mycoplasma hominis meningitis in a premature infant. Azithromycin treatment was administered due to a positive amniotic fluid culture for Mycoplasma hominis. On the 13th day after birth, the infant exhibited tachycardia and decreased blood pressure, and was assisted with invasive ventilation. After blood and cerebrospinal fluid (CSF) cultures were sent for examination, meropenem and vancomycin were administered for anti-infection treatment. CSF analysis revealed a predominance of polynuclear leukocytes, and no bacterial growth was found in blood and CSF cultures. The infant was transferred to our hospital on the same day with fever, and was treated with meropenem, vancomycin, and azithromycin. After three days of hospitalization, the infant's body temperature returned to normal, and vancomycin was discontinued. The infant's clinical symptoms gradually improved, and the number of white blood cells in the CSF gradually decreased. On the 19th day, the infant had frequent episodes of apnea, and high-throughput sequencing of pathogenic microbial nucleic acid in CSF detected Mycoplasma hominis. On the 20th day, meropenem was discontinued, and azithromycin was continued for a total of 21 day. The infant was discharged in good condition, with no obvious neurological complications or sequelae.

Conclusions

We report a case of Mycoplasma hominis meningitis in a premature infant that was successfully treated with azithromycin. A review of the literature revealed that Mycoplasma hominis meningitis in neonates may have a favorable prognosis with non-specific treatment under certain conditions.

Mycoplasma hominis

Mycoplasma hominis meningitis

meningitis

neonates

Neonatal

Mycoplasma hominis predominantly inhabits the human urogenital tract, resulting in infections of the reproductive and urinary systems, as well as negative effects during pregnancy^[1]. Pregnant women who are infected with this microorganism can pass it on to their newborns during delivery, which increases the likelihood of Mycoplasma hominis colonization in neonates from the beginning^[1]. This poses a possible hazard for both infants born at full term and those born prematurely. While instances of newborn meningitis caused by this pathogen are few, central nervous system infections with symptoms such as fever and seizure can nonetheless manifest^[2]. At present, professional organizations have not provided particular treatment guidelines for neonatal Mycoplasma hominis infections. However, drugs such as moxifloxacin, ciprofloxacin, and doxycycline have been utilized to treat mycoplasmal meningitis^{[3, 4]}. In this study, we present a case of neonatal Mycoplasma hominis meningitis and conduct a comprehensive assessment of the existing literature on instances of neonatal Mycoplasma hominis meningitis that showed clinical improvement without the requirement of targeted anti-mycoplasma treatment.

A primigravida at 30 + 1 weeks of pregnancy received a cesarean section owing to "arrest of descent" 44 hours after spontaneous rupture of membranes at a local hospital. The amniotic fluid exhibited transparency, the umbilical chord displayed typical characteristics, and the Apgar scores at 1, 5, and 10 minutes all registered a perfect score of 10. The birth weight was 1750 grams. The mother, aged 43, is managing gestational diabetes through the use of insulin.

The neonate presented with tachypnea, moaning, and retractions after birth and was subsequently admitted to the neonatal unit of the local hospital. Non-invasive breathing was administered, and empirical antibiotic treatment with penicillin and ceftazidime was commenced. Azithromycin was given for 3 days after a positive mycoplasma hominis culture was found in the amniotic fluid. The infant's status remained rather steady until the 13th day of life, when a sudden clinical deterioration occurred, characterized by tachycardia, hypotension, and a C-reactive protein level of 76.53 mg/dl. The patient was put on invasive mechanical breathing, and the antibiotics were switched to meropenem and vancomycin for 3 days. The respiratory and circulatory conditions of the infant showed signs of improvement. The Cerebrospinal fluid (CSF) showed a white blood cell count of 310×10⁶/L (80% polymorphonuclear cells). The protein was measured at 1.58 g/L, and the glucose level was found to be 1.74 mmol/L. The CRP in the blood test has elevated to 110.61 mg/dl. The infant was transferred to the Neonatal Department of Guangzhou Women and Children's Medical Center, which is associated with Guangzhou Medical University.

Following admission, the kid had a fever, and the anteroposterior X-ray revealed newborn pneumonia along with a hypersensitive CRP of 125.26 mg/dL. The patient received ongoing invasive breathing support and underwent a lumbar puncture procedure. The CSF exhibited a white blood cell count of 151×10⁶/L (80% polymorphonuclear cells), protein at 2.12 g/L, glucose at 2.11 mmol/L, chloride at 119 mmol/L, and LDH at 59 U/L. The administration of meropenem, vancomycin, and azithromycin was started as a practical approach to antimicrobial therapy. No microorganisms were identified using CSF Gram stain, CSF culture, blood culture, or metagenomic sequencing of bloodborne infectious pathogens. On the 16th day of the patient’s life, they were transitioned on non-invasive ventilation support. After three days, the temperature returned to normal, and the use of vancomycin was stopped. However, the therapy with meropenem and azithromycin was still ongoing. On the 19th day, the infant had numerous episodes of apnea and received endotracheal intubation for invasive ventilation assistance. Simultaneously, routine and biochemical analysis of CSF revealed a white blood cell count of 79×10⁶/L (82% polymorphonuclear cells), protein at 2.60 g/L, glucose at 1.97 mmol/L, chloride at 121.1 mmol/L, and LDH at 51 U/L. Mycoplasma hominis was identified in CSF using high-throughput sequencing of pathogen nucleic acids, with a sequence count of 423. No more pathogenic microorganisms exhibited growth. As a result of the child's clinical symptoms improving and their condition stabilizing, the white blood cell count in the CSF reduced. Therefore,

meropenem was stopped on the 20th day after childbirth, and therapy with azithromycin was continued. During this time frame, two extra CSF samples were obtained via lumbar puncture. The protein levels gradually decreased as the glucose levels simultaneously increased, and no growth of microorganisms was seen during the entire procedure. Table 1 displays the results of the CSF analysis conducted during the patient's hospitalization. Azithromycin was stopped on the 35th day. On the 42nd day, a brain MRI showed the presence of purulent meningitis with subdural empyema on both sides of the parieto-occipital region, as well as a little enlargement of the right ventricle. The neurosurgical evaluation revealed a minor empyema region and no notable enlargement of the ventricles, with no indications for surgical intervention. On the 51st day, subsequent head MRI scans revealed increased absorption of the empyema, however the right ventricular enlargement remained stable. On the 64th day, the use of non-invasive ventilation was stopped. After a period of 69 days in the hospital, the patient was released without any significant neurological issues or aftereffects. Following release, the kid will undergo outpatient follow-up at the local hospital to assess growth and evaluate neurodevelopmental status.

Mycoplasmas are the tiniest microbes that can survive on their own. Mycoplasma hominis is a constituent of the typical vaginal microbiota in women^[5]. By adulthood, up to 50% of healthy women have Mycoplasma hominis present in their cervical or vaginal secretions^[6]. The colonization of Mycoplasma hominis in neonates is believed to occur due to exposure either during transit through the birth canal or through exposure in the utero^[7]. Colonization is correlated with reduced birth weight and premature delivery^[7]. Mycoplasma hominis is frequently present in the amniotic fluid of individuals experiencing spontaneous preterm labor, preterm premature rupture of membranes, term premature rupture of membranes, low birth weight infants, spontaneous abortion, and stillbirth^[8]. Research has indicated that administering potent antibiotics to pregnant women who are at risk of preterm labor and are infected with mycoplasmas can prolong the duration of their pregnancy, suggesting an association between these microorganisms and adverse pregnancy outcomes ^[9].

Neonatal Mycoplasma hominis infections exhibit a wide range of clinical symptoms and can occur soon after birth. The primary symptoms comprise of respiratory distress, recurrent fever, inadequate eating, and lethargy. These symptoms are frequently accompanied by the presence of bacteria in the bloodstream and congenital pneumonia. In extreme instances, they can cause issues in the central nervous system, such as meningoencephalitis and abscesses, which can ultimately lead to death

^{[10, 11]}. While Mycoplasma hominis infections are uncommon, it is important to consider the possibility of infection with these microorganisms when systemic infections, pneumonia, and central nervous system infections occur. This is particularly true when blood cultures and Gram staining yield negative results at an early stage and there is no improvement after conventional antibiotic treatment. Mycoplasma hominis normally proliferates in liquid culture media within 24–48 hours, although it may require up to a week to develop identifiable colonies that resemble "fried eggs". Occasionally, it can also proliferate on traditional bacterial culture media, forming pinpoint colonies. A real-time polymerase chain reaction (PCR) assay has been designed to specifically identify Mycoplasma hominis DNA. This diagnostic approach can be utilized for varied patient samples^[12].

The optimum treatment for Mycoplasma hominis meningitis has not yet been established, and there is limited clinical evidence available for neonatal mycoplasmal meningitis, consisting mostly of case reports and tiny case series investigations. Antibiotic treatment regimens are typically chosen empirically, frequently without the availability of antimicrobial susceptibility testing findings. When the clinical efficacy is unsatisfactory and the treatment is unsuccessful, susceptibility testing should be taken into consideration. Ureaplasma urealyticum is susceptible to macrolide antibiotics, but Mycoplasma hominis inherently demonstrates resistance to macrolide antibiotics^[13]. Standard in vitro antibiotic susceptibility tests exist for Mycoplasma hominis, and there are also interpretive criteria for minimum inhibitory concentrations (MICs) for numerous drugs^[14]. In laboratory conditions, Mycoplasma hominis is generally susceptible to

the following medications: tetracyclines such as doxycycline ^[15–17]; clindamycin^[15–17]; fluoroquinolones such as levofloxacin and moxifloxacin ^{[18, 19]}. Mycoplasma hominis in vitro commonly exhibits resistance to the following medications: macrolides (such as erythromycin, azithromycin, and clarithromycin), aminoglycosides, sulphonamides, trimethoprim, and all β-lactams^[20]. Several investigations have indicated that azithromycin is not successful in treating Mycoplasma hominis, since it has a sensitivity rate of 0% for Mycoplasma hominis^[21].

Literature reports have indicated that newborn mycoplasma meningitis has a favorable prognosis when treated with specific antibiotics. However, other publications claim that instances have shown improvement even without specialized anti-mycoplasma medication or any treatment at all. In this report, we provide a case of mycoplasma meningitis in a premature newborn who was treated with azithromycin and discharged after recovering without any notable long-term neurological sequelae. We conducted a comprehensive search of both Chinese and English literature to identify cases of newborn meningitis that were either not given particular anti-mycoplasma medication or were left untreated. The details of these cases may be found in Table 2. There have been a total of 21 recorded cases, consisting of 15 preterm infants and 6 term infants. The analysis of these instances revealed that 8 births were performed via cesarean section, 9 births occurred through vaginal delivery, and the delivery mode for 4 cases remains uncertain. A 35-week-old premature newborn became sick on the eighth day after being born, displaying symptoms such as fever, convulsions, irritability, apnea, bradycardia, and muscle weakness, the CSF displayed heightened numbers of white blood cells, protein, and reduced glucose levels, this newborn did not undergo antibiotic therapy and subsequently developed right hemiplegia^[22]. A 32-week-old preterm newborn, with a birth weight of 2440 grams, passed away without being administered antibiotics for reasons that are not known^[23]. Furthermore, a 34-week-old premature newborn with Down syndrome was not administered antibiotics and was left with developmental delay^[24]. Multiple additional infants displayed neurological signs, however, all of them had positive prognoses without any long-term neurological consequences. The prognosis of neonatal mycoplasma meningitis may be influenced by the extent of neurological involvement. If there are no or just minimal neurological issues, a favorable outcome can still be attained even without particular anti-mycoplasma treatment.

Instances of neonatal Mycoplasma hominis meningitis are exceedingly uncommon, and the complete understanding of their natural progression and immune reaction is still lacking. The amelioration of the infant's clinical symptoms does not necessitate targeted anti-Mycoplasma therapy, maybe attributable to the subsequent rationales and mechanisms: 1. The immunological reaction of the newborn. While the immune system of premature infants may not be as developed as that of full-term infants, it nevertheless possesses a certain capacity to combat infections^[25]. Under some circumstances, natural killer cells and macrophages have the ability to identify and eradicate infected cells, hence decreasing the amount of pathogens present. Simultaneously, cytokines and chemokines can activate other components of the immune system to augment overall resistance to infections.2. Immune response of the mother. Certain antibodies passed from the mother via the placenta may have also provided protection. 3. Indirect consequences of broad-spectrum antibiotics. While certain trials did not utilize particular anti-Mycoplasma medications, the use of empirically administered broad-spectrum antibiotics may still prove effective in combating other bacteria that are co-infected, thus indirectly enhancing the overall condition. Co-existing bacterial infections can be effectively treated with broad-spectrum antibiotics, which can reduce the total infection load and indirectly assist in managing Mycoplasma infections. 4. The inherent tendency of Mycoplasma infections to naturally resolve on their own. Mycoplasma infections have the potential to resolve spontaneously, without the need for specific treatment, particularly when the infection is not severe^[26]. 5. Minimal pathogenicity. Individuals may exhibit varying levels of pathogenicity when infected with Mycoplasma hominis. Certain strains of the bacteria may have reduced virulence, resulting in milder situations that either lack substantial neurological signs or have less severe neurological symptoms. 6. Additional treatment and assistance in managing symptoms. Newborns in neonatal intensive care units typically get extensive supportive care, which encompasses respiratory assistance and nutritional support. These interventions can indirectly contribute to the infant's recovery. 7. Testing procedures may be prone to errors or delays. Occasionally, when a diagnosis is established, the ailment may have already ameliorated, and additional unidentified infections may have significantly contributed. The aforementioned parameters may synergistically contribute to the amelioration and recuperation of neonatal Mycoplasma meningitis. Without further extensive investigation and data support, it may be challenging to precisely pinpoint the actual mechanism. However, the aforementioned reasons and mechanisms are plausible

answers.

The management of newborn Mycoplasma hominis meningitis should be tailored based on the infant's clinical status. Infants who do not have any difficulties or severe neurological complications may not need particular treatment for mycoplasma infection. However, in the context of professional practice, it is important to exercise caution when dealing

with such illnesses. This involves promptly and accurately diagnosing the infection and providing appropriate therapy in order to achieve the most favorable prognosis.

Table 1

Cerebrospinal Fluid Analysis During the Hospitalization of the Infant
Age(d)	WBC (*10⁶/L)	Protein (g/L)	Glucose (mmol/L)	Cl (mmol/L)	LDH (U/L)	culture	Microscopic examination
16	151	2.12	2.11	119.0	59	N	N
19	79	2.60	1.97	121.1	51	N	N
23	59	2.18	1.65	120.1	55	N	N
29	43	2.12	2.21	125.1	43	N	N
35	9	1.68	2.13	121.7	34	N	N
42	4	1.47	2.15	122.5	30	N	N

WBC: white blood cell. Cl: chloride. LDH: lactate dehydrogenase. N: negative

Table 2

Characteristics of Neonatal Mycoplasma hominis Meningitis without Specific Anti-mycoplasma Treatment
Study	Gender	Gestational age (weeks)	Delivery	Birth Weight	Onset Age (days)	Clinical manifestations	Routine test and biochemistry indicators of CSF	Diagnostic method	Outcome
Yan-Fen Huang, et. al	Female	NA	NA	4000	11	Fever, hydrocephalus	WBC ↑ Protein↑ Glucose↓	culture	Alive, hydrocephalus
Marta Knausz, et. al	Male	41	NA	4340	10	Fever, seizure, hydrocephalus, Vomit	WBC ↑ Protein↑ Glucose↓	culture	Alive
Ken.B Waites,et.al	Male	39	C	4080	1	NA	WBC- Protein↑ Glucose ND	culture	Alive
	Female	42	C	3500	1	NA	WBC - Protein - Glucose ND	culture	Alive
	Male	37	C	2900	3	NA	WBC - Protein↑ Glucose ND	culture	Alive
R. David Mcnaughton, et.al	Female	NA	NA	3290	10	Vomit, Feeding difficulties	WBC - Protein ↑ Glucose –	culture	Alive
Guanglu Che, et.al	Female	36	V	2500	6	Fever	WBC ↑ Protein↑ Glucose↓	mNGS	Alive
Louise Watson, et.al	Male	24	V	623	13	Seizure	WBC ↑ Protein↑ Glucose↓	culture	Alive
Sunil Sethi, et.al	NA	NA	NA	NA	NA	NA	NA	culture	Alive
KEN B.WAITES, et,al	Female	32	C	1500	NA	NA	WBC - Protein - Glucose ND	culture	Alive
	Male	33	V	2700	NA	NA	WBC- Protein- Glucose ND	culture	Alive
	Male	28	C	1120	NA	NA	WBC- Protein- Glucose ND	culture	Alive
	Male	35	V	2750	NA	NA	WBC ↑ Protein↑ Glucose ND	culture	Alive
	Male	32	C	2440	NA	NA	WBC - Protein - Glucose ND	culture	Death
	Male	33	V	1800	NA	NA	WBC - Protein ↑ Glucose ND	culture	Alive
KEN B.WAITES, et,al	Male	34	V	2180	NA	NA	WBC - Protein ↑ Glucose ND	culture	Alive, neurodevelopment disorder
	Female	34	C	2840	NA	NA	WBC - Protein↑ Glucose ND	culture	Alive
	Male	34	V	2350	NA	NA	WBC- Protein↑ Glucose ND	culture	Alive
	Male	29	C	1000	NA	NA	WBC- Protein↑ Glucose ND	culture	Alive
George R. Siber, et,al	Male	35	V	1530	8	Fever, seizure, hydrocephalus, apnea, Bradycardia, hypomyotonia	WBC ↑ Protein↑ Glucose↓	culture	Alive, paralysis
0YDIS B0E, et,al	Male	29	V	1550	14	Fever, seizure, hydrocephalus	WBC ↑ Protein ND Glucose ND	Culture + FAT	Death

CSF: cerebrospinal fluid. ND: not done. WBC: white blood cell. C: C-section delivery. V: Vagrinal delivery. NA: not acquired.

Acknowledgements

Not applicable.

Authors’ contributions

Xiaoling Zhang, Fan Li, and Meigui Wu conceptualized the idea of writing this case report. Xiaoling Zhang drafted the initial manuscript which was revised by Ling Wang and Juncao Chen. Ping Wang supervised the literature review, critically reviewed the manuscript, and approved the final version.

Funding

No funding received from any public, commercial or non-profit organization.

Availability of data and materials

Not applicable.

Ethics approval and consent to participate

None.

Consent for publication

Written informed consent was obtained from patient’s parents for

publication of this case report.

Competing interests

The authors declare that they have no competing interests.

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Case report and literature study on the resolution of Neonatal Mycoplasma hominis meningitis with non-specific therapy

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