Acquired mutations on the ribosomal macrolide target are the only resistance mechanism described [2]

Acquired mutations on the ribosomal macrolide target are the only resistance mechanism described [2]. bronchodilators were initiated. Her clinical course was complicated by hypoxic respiratory failure, hemoptysis, and worsening of infiltrates, requiring intubation and mechanical ventilation. Bronchoscopic bronchoalveolar lavage was consistent with diffuse alveolar hemorrhage (DAH). The patient’s serum was positive for IgM antibody to Mycoplasma pneumoniae [1134 U/mL] and Anti-I-specific IgM-cold-agglutining [1:40]. A diagnosis of severe mycoplasma infection with DAH was made. The patient was treated with an additional course of doxycycline, pulse dose steroids and plasmapharesis with good clinical response. Surgical lung biopsy showed focal acute lung injury. Bone marrow biopsy and fat pad biopsy were normal. She was liberated from mechanical ventilation and Triacsin C discharged. She returned within 24 hours of discharge with cardiac arrest and new onset right-bundle-branch-block. We hypothesize our patient had severe mycoplasma pneumonia with DAH and multisystem complications of the same including a possible venous thrombo-embolic episode leading to her demise. infections. infection have been associated with DAH [11]. Severe mycoplasma with MP-associated DAH is rare, with only two cases identified in the English literature [3], [4]. Diagnosis is based on findings of hemoptysis, anemia, diffuse or worsening infiltrates, and hypoxemic respiratory failure. Bronchoscopy showing hemorrhagic sequential lavage and hemosiderin-laden macrophages support the diagnosis. The latter is usually found after 48C72 hours of hemoptysis [12]. The diagnosis of MP infection is based on serology, particularly IgM detection by ELISA. Sensitivity of IgM assays increases with the duration of symptoms, approaching more than 70% after 16 days of symptoms [13]. The positive predictive value for most of the test ranges from 60 to 80% [13]. Cross-reactivity with Epstein Barr Virus (EBV) is common. Cold agglutinins helps to confirm the diagnosis, they are increased in 50C60% of patients, but may occur in EBV, cytomegalovirus, or infection. Anti-I-specific IgM-cold-agglutinin is more specific for diagnosis [14]. PCR and Triacsin C serological analyses could be good screening tests for the reliable and accurate diagnosis of MP [2]. Bacterial culture is time-consuming and not readily available [2]. The Japanese Respiratory Society scoring system for atypical pneumonias is able to diagnose MP pneumonia with 88.7% sensitivity and 77.5% specificity [15]. The presence of more than four out of THY1 six of the following parameters provides high suspicion for MP; age 60 years, absence of or minor underlying diseases, stubborn cough, positive findings in chest auscultation, absence of sputum, or identifiable etiological agent by rapid diagnostic testing and serum white blood Triacsin C cell count 10??109/L [15]. Our patient exhibited five parameters, and in addition elevated IgM and high anti-I- specific cold agglutinin levels. Other causes of DAH were ruled out by appropriate serological tests. It is imperative that an etiological diagnosis for DAH be established to initiate appropriate therapy. In patients with MP infection, macrolides are the drug of choice in adults and children; however, there are growing concerns regarding the development of resistance Triacsin C [1]. Acquired mutations on the ribosomal macrolide target are the only resistance mechanism described [2]. Resistance in Europe and USA may be in upto a quarter of patients, whereas resistance in Japan and China may be approaching more than 90% [16]. Therapeutic alternatives include fluoroquinolones, primarily levofloxacin, and tetracyclines [1], [17]. The management of DAH is supportive. Corticosteroid Triacsin C and immunosuppressive therapies are controversial [11]. Daily or alternate day plasmapharesis may be considered according to the guidelines of the American Society for Apheresis in patients with DAH presenting with severe hypoxemic respiratory failure [18], [19]. 4.?Conclusions Diffuse alveolar hemorrhage in a patient with CAP should raise suspicion for severe MP infection. Cases may be missed due to low suspicion. The Japanese Respiratory Society Scoring System may prove useful in these scenarios. Mycoplasma pneumonia should be included as part of the differential diagnosis in patients with CAP and multi-organ involvement. Plasmapheresis may be lifesaving and should be considered for severe DAH associated with.