Associate Staff Cleveland Clinic Avon, Ohio, United States
Case Diagnosis: 17 year old female with Mycoplasma encephalitis
Case Description: A 17 year old female with prior epilepsy who had been seizure-free off medications for over a year presented with new seizures and altered mental status. MRI revealed a hyperintense nonenhancing lesion, with full analysis consistent with encephalitis. Further workup revealed elevated Mycoplasma pneumoniae IgG and IgM blood titers. CSF demonstrated a lymphocytic pleocytosis without detection of mycoplasma. She completed courses of solumedrol, IVIG, and azithromycin with minimal improvement in symptoms. A triple-agent antiepileptic drug regimen was initiated, eventually controlling seizure activity. She was admitted to inpatient rehab where therapies focused on her ataxic gait, impaired upper body coordination, and severely apraxic speech. She made significant improvements in regaining physical mobility, though her speech remained impaired. After discharge, she continued to make progress in outpatient therapies and was eventually able to resume school at grade level activities.
Discussions: Mycoplasma encephalitis is a rare central nervous system manifestation of mycoplasma pneumoniae. CNS involvement without respiratory manifestations is even rarer. Often the diagnosis is confirmed through MRI and elevated Mycoplasma pneumoniae IgM and IgG titers, while CSF may remain negative for mycoplasma. In this patient, the onset of new seizures after having previously achieved full seizure control was a strong indicator for a novel etiology behind her new epileptiform activity. Treatment options for the infection are limited; only some patients respond to solumedrol, IVIG, or azithromycin. Although a patient may have minimal response to treatments for mycoplasma, inpatient rehab can still be beneficial through focusing on addressing functional deficits as well as achieving control of symptoms such as seizures.
Conclusions: Improvement in functional mobility and cognition both during and after inpatient rehabilitation indicates a strong benefit to focused therapies, despite initial lack of improvement with medications alone for Mycoplasma encephalitis.