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1 Department of Emergency Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
2 Division of Endocrinology and Metabolism, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
3 Department of Pediatrics, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
4 Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
5 Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
6 Department of Life Sciences, National Central University, Taoyuan, Taiwan
Address correspondence to:
Po-Jen Hsiao
MD, Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taiwan No. 168, Zhongxing Rd., Longtan Dist., Taoyuan City 325,
Taiwan, R.O.C.
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Article ID: 101239Z01KH2021
No Abstract
Keywords: Mycoplasma pneumoniae, Subconjunctival hemorrhage
A 6-year-old boy presented with productive cough, vomiting, and fever for three days. There was no coagulopathy and no history of trauma. Physical examination revealed crackling sounds over the right lung, cutaneous rash over the periorbital region, and noticeable subconjunctival hemorrhage of the right eye (Figure 1). Both the adenovirus antigen test and influenza A/B antibody tests from nasopharyngeal aspirate were negative. Chest X-ray demonstrated infiltration over the right lung. Laboratory examination revealed white blood cells (3620/μL), hemoglobin (12.5 g/dL), C-reactive protein (0.53 mg/dL), and impaired hepatic function (aspartate aminotransferase: 67.6 U/L, alanine aminotransferase: 48.2 U/L). The serum immunoglobulin M antibody test for Mycoplasma pneumoniae was positive. The diagnosis of M. pneumoniae was made. After oral azithromycin treatment for three days, his general condition improved, and subconjunctival hemorrhage subsided after one week of follow-up.
Mycoplasma pneumoniae, a common cause of respiratory tract infection, can lead to associated extrapulmonary manifestations. Skin presentations such as erythema multiforme major have been reported to occur in approximately 25% of children [1]. The clinical characteristics of Mycoplasma-induced rash and mucositis are oral, ocular, and urogenital mucositis with variable severity, especially in young males. The pathophysiology may be responsible for (1) polyclonal B-cell proliferation and antibody production resulting in skin damage stemming from immune complex deposition and complement activation or (2) molecular mimicry between Mycoplasma P1-adhesion molecules and a keratinocyte antigen [2],[3]. Stevens-Johnson syndrome (SJS) and erythema multiforme are immune-mediated disorders characterized by prodromal illness followed by serious mucocutaneous symptoms. They are usually characterized by extensive mucositis and ocular disease. In a previous retrospective case-control study, children with M. pneumoniae-associated SJS were significantly more likely to have more respiratory symptoms, radiographic pneumoniae, and an elevated erythrocyte sedimentation rate (ESR) than children with non–Mycoplasma-associated SJS [4].
The common causes of subconjunctive hemorrhage include hypertension, arteriosclerosis, diabetes mellitus, trauma, acute hemorrhagic conjunctivitis, anticoagulant therapy, conjunctivochalasis, and wearing contact lenses. However, subconjunctive hemorrhage may be a rare complication of M. pneumoniae infection. These manifestations may be closely related to inflammation, infection, and tissue damage caused by M. pneumoniae. Other ocular manifestations, including anterior uveitis, optic papillitis, and amaurosis, have been reported to be associated with M. pneumoniae infection [5],[6]. However, our patient did not have evidence of inflammatory or infectious conjunctivitis, and his subconjunctival hemorrhage could not be explained by direct infection of the conjunctiva. The possible etiology in this boy is prolonged, vigorous coughing or vomiting, which may increase venous pressure and congestion and induce hemorrhage in the orbit, anterior chamber, or subconjunctive space. It is usually benign and resolves spontaneously [1]. In particular, cough may be the most common symptom of M. pneumoniae infection. Therefore, controlling a prolonged cough with antitussive medicine may decrease the possibility of subconjunctival hemorrhage. The condition is usually benign and subsides spontaneously; it usually resolves within 5–10 days [7]. In addition, M. pneumoniae usually affects infants and young children, and the symptoms are similar to infections with other respiratory viruses. In future epidemics, assessment of extrapulmonary manifestations may be helpful when diagnosing M. pneumoniae infections [7].
In summary, this case report presented subconjunctival hemorrhage in a 6-year-old boy with M. pneumoniae. Clinical physicians should be aware that respiratory symptoms such as severe coughing and vomiting or the Valsalva manoeuvre can cause subconjunctival hemorrhage in infants and children with respiratory tract infections.
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Kuo-Yuan Hsu - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Chih-Chun Kuo - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Min-Tser Liao - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Po-Jen Hsiao - Conception of the work, Design of the work, Acquisition of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
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