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of Child Neurology

Posterior Cerebral Artery Occlusion Associated With Mycoplasma pneumoniae Infection
Charalampos Antachopoulos, Theodota Liakopoulou, Fani Palamidou, Dimitra Papathanassiou and Sotiris
Youroukos
J Child Neurol 2002 17: 55
DOI: 10.1177/088307380201700115
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55

Posterior Cerebral Artery Occlusion Associated
With Mycoplasma pneumoniae Infection

Case Report
An 8-year-old boy was referred to our department with a 2-day history of
acute-onset, right-sided hemiparesis. Two weeks prior to admission, he
had developed a dry cough, followed by moderate fever 5 days later. At that
time, he was seen by a pediatrician and was treated with a course of oral

ABSTRACT
Cerebral infarction is a rare complication of Mycoplasma pneumoniae infection. In all cases previously reported in the literature,
vascular occlusion occurred in the anterior brain circulation, either
the internal carotid or the middle cerebral artery. We report a case
of a child with posterior cerebral artery occlusion and resultant

hemiparesis associated with M. pneumoniae infection. (J Child
Neurol 2002;17:55-57).

Cerebral infarction is a rare neurologic complication of Mycoplasma
pneumoniae infection. It is usually manifested as hemiparesis but
has also been associated with facial palsy.5 A total of nine cases of
cerebral infarction after serologically proven M. pneumonia infection have been reported in the literature, including four adults and
five children.’-’ In all of these cases, vascular occlusion occurred
in the anterior circulation of the brain, either in the internal carotid
or the middle cerebral artery, a fact that has been pointed out by
previous authors.4 We report a case of posterior cerebral artery occlusion in an 8-year-old boy after M. pneumonia infection.

cefprozil and inhaled salbutamol. His past medical and family history were
unremarkable, apart from the fact that his mother had the sickle cell trait.
On admission, he was afebrile, fully conscious, and oriented, with a
blood pressure of 110/70 mm Hg. Muscle strength was markedly diminished
in the right arm and leg, but sensation was normal. Tendon reflexes were
asymmetric, more brisk on the right side. Babinski reflexes were present
on the right. Cranial nerves were intact. The rest of the physical examination, including cardiovascular and respiratory systems, was unremarkable.
Brain computed tomography (CT) on admission demonstrated a small
area of decreased density in the left thalamus. This finding was confirmed
by a magnetic resonance imaging (MRI) scan 2 days later, which revealed
an infarct in the left thalamus also affecting the posterior part of the internal capsule (Figure 1). Magnetic resonance arteriography of the brain, performed on the same day, demonstrated marked stenosis (almost complete
occlusion) of the left posterior cerebral artery near the bifurcation of the
basilar artery, with faint signal of the distal branches of the left posterior
cerebral artery (Figure 2).
Laboratory investigations revealed a white blood cell count of
17,300/jjbL, with 86% neutrophils, 8% lymphocytes, and 6% monocytes; hemoglobin 12.3 g/dL; and platelets 353,000/jjbL. The biochemistry and lipid profile were within normal limits. Hemoglobin studies revealed the presence
of Hb S at 38.5% and Hb F at 0.7%, with a confirmatory sickle testing. These
findings were consistent with sickle cell trait. Extensive coagulation studies, including plasma levels of clotting factors, serum proteins C and S, plasminogen and antithrombin III, and testing for the lupus anticoagulant, did
not reveal any abnormalities. Anticardiolipin, antinuclear, and anti-DNA antibody tests were negative. Screening for homocystinuria in plasma and
urine was negative. The cerebrospinal fluid, chest radiography, electrocardiography, and echocardiography, were normal. Antibodies to specific
infectious agents that are known to be associated with stroke, such as
varicella-zoster virus, Chlamydia pneumoniae, and Borrelia burgdorferi, ~ were negative. However, antibody titers to M. pneumoniae, determined
by the enzyme-linked immunosorbent assay, were IgG 1:1280 and IgM
1:1280 2 days post admission, followed by IgG 1:640 and IgM negative 3 weeks
later. These findings indicated acute M. pneumoniae infection.’7
The patient was given a 2-week course of clarithromycin and a 1-month
course of low-dose aspirin (1 mg/kg of body weight daily). Early physiotherapy was also started. There was a remarkable and steady improvement of motor function. He was re-examined 3 months later, and only mild
pyramidal signs could be seen on the right side. A repeated magnetic resonance arteriography of the brain demonstrated persistence of the stenosis in the proximal part of the left posterior cerebral artery, with an almost
normal signal of the distal branches of the left posterior cerebral artery.
Discussion
Our patient was extensively investigated for possible causes of cerebral infarction and was found to have serologic evidence of recent
M. pneumoniae infection, which was consistent with the relevant

history of cough and fever. He was also found to have the sickle
cell trait. Although cerebral infarction is a rare but recognized
complication of M. pneumoniae infection, one could question the
role of the sickle cell trait in this case. Sickle cell trait is associ-

ated with a benign clinical course and is not a recognized risk factor for ischemic stroke in children. Vaso-occlusive complications

may occur only in the presence of predisposing factors leading to
severe hypoxia, such as general anesthesia.&dquo; Such conditions were
not suggested by the patient’s history.

By reviewing the literature, we did find two reports of cereFigure 1. T 2-weighted MRI demonstrating infarction in the area of left
thalamus also affecting the posterior part of the internal capsule.

bral infarction in children with the sickle cell trait in whom no pre-

disposing factor to hypoxia was identified by the authors.9,&dquo; One

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56

The course of hemiparesis varied from complete resolution within

2 months to permanent mild unilateral spasticity.
The pathogenesis of neurologic complications after

Mycoplasma infection is not fully understood. Different mechanisms
have been proposed, including direct invasion of the central nervous system by the organism, production of autoantibodies, or formation of immune complexes and, less likely, the release of
neurotoxin. ~-5, ~ ~-~4 The uncertainty of the pathogenesis makes the
treatment of these complications difficult. Depending on the

patient’s condition, antibiotics, corticosteroids, other anti-inflammatory agents, and plasma exchange have been tried, with variable
results. 1-5,7,11-14 The use of low-dose aspirin (1 mg/kg of body weight

Figure 2. Magnetic resonance arteriography demonstrating almost
complete occlusion of the left posterior cerebral artery near the bifur-

daily) has been advocated by some authors for patients with vascular occlusion.’ Prognosis is related to the type of neurologic
complication. Mortality is higher in patients with encephalitis or
polyneuropathy, reaching 8 to 10%. Full recovery is common, but
up to one third of patients may have permanent neurologic sequelae.2,5,11,14 This outcome could probably be improved with the implementation of new therapeutic strategies based on further research
and understanding of the pathogenesis of central nervous system
complications associated with M. pneumoniae infection.

cation of the basilar artery.

Charalampos Antachopoulos, MD
Theodota Liakopoulou, MD
Fani Palamidou, MD
Dimitra Papathanassiou, MD
Sotiris Youroukos, MD
First Department of Pediatrics
Athens University
"Aghia Sophia" Children’s Hospital
Athens, Greece

should be very cautious, however, when evaluating these two
cases. The failure to

identify any precipitating or other risk factors

for ischemic stroke in these patients does not necessarily imply the
lack of their existence. The frequency of sickle cell trait is high in
certain population groups (about 8% in African Americans),8 and

if this was indeed a risk factor for stroke in childhood, far more
than two cases should have been reported in the literature. Con-

sequently, the primary cause of the posterior cerebral artery infarct
in our patient was thought to be the recent MycopLasma infection.

However, given the fact that the precise mechanism of neurologic
complications associated with M. pneumoniae has not yet been
elucidated, the possibility that the presence of Hb S (38.5%) played
a role in the sequence of events triggered by the MycopLasma
infection could not be excluded.

Received Feb 12, 2001. Received revised July 12, 2001. Accepted for publication July 27, 2001.
Address correspondence to Dr Sotiris Youroukos, 15 Gounari str., 15124
Marousi, Athens, Greece. Tel: 00301-8061714; fax: 00301-8023703; e-mail:

sotel@hol.gr.

References

Besides cerebral infarction, M. pneumoniae-associated neu-

rologic complications include encephalitis, meningoencephalitis,
myelitis, neuropathies, Guillain-Barr6 syndrome, ataxia, choreoathetosis, and psychosis.7,11-14 Cerebral infarction is a rare complication, with a total of four adult and five pediatric cases reported
to date, all involving the anterior brain circulation (internal carotid,
middle cerebral artery).’-5 Our patient is the first case reported in
whom the infarct involved the posterior brain circulation.
In the above five pediatric patients with M. pneumoniaeassociated cerebral infarction (aged 4-12 years, including four
girls), vascular occlusion occurred 6 to 10 days after the onset of
the respiratory illness. 1-5 It was manifested as hemiparesis (four
cases)&dquo; or isolated facial palsy (one case),5 without changes in mental status. Conventional or magnetic resonance angiography confirmed the diagnosis in three patients,2&dquo; whereas in the remaining
two children, cerebral infarction was demonstrated on a CT or MRI
brain scan.’~5 In all cases, MycopLasma infection was established
serologically by enzyme-linked immunosorbent assay or a complement fixation test. Isolated facial palsy resolved within 2 weeks.

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Parker P, Puck J, Fernandez F: Cerebral infarction associated with
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Visudhiphan P, Chiemchanya S, Sirinavin S: Internal carotid artery
occlusion associated with Mycoplasma pneumoniae infection. Pediatr Neurol
1992;8:237-239.
Ganesan V, Savvy L, Chong WK, Kirkham FJ: Conventional cerebral
angiography in children with ischemic stroke. Pediatr Neurol
1999;20:38-42.
Fu M, Wong KS, Lam WWM, Wong GWK: Middle cerebral artery occlusion after recent Mycoplasma pneumoniae infection. J Neurol Sci
1998; 157:113-115.
Papaevangelou V, Falaina V, Syriopoulou V, Theodordou M: Bell’s
palsy associated with Mycoplasma pneumoniae infection. Pediatr
Infect Dis J 1999; 18:1024-1026.
Kirkham FJ: Stroke in childhood. Arch Dis Child 1999;81:85-89.
Thomas NH, Collins JE, Robb SA, Robinson RO: Mycoplasma pneumoniae infection and neurological disease. Arch Dis Child
1993;69:573-576.
Honig GR: Hemoglobin disorders, in Behrman RE, Kliegman RM, Jenson HB (eds): Nelson Textbook of Pediatrics, 16th ed. Philadelphia,
WB Saunders, 2000, 1478-1488.
Riggs JE, Ketonen LM, Wang DD, Valanne LK: Cerebral infarction in
a child with sickle cell trait. J Child Neurol 1995;10:253-254.

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Leavitt JA, Butrus SI: Internuclear ophthalmoplegia in sickle cell trait.
1994;14:49-51.
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Neuroophthalmol
Koskiniemi M: CNS manifestations associated with Mycoplasma
pneumoniae infections: Summary of cases at the University of Helsinki
and review. Clin Infect Dis 1993;17(Suppl 1):S52-S57.
Abramovitz P, Schvartzman P, Harel D, et al: Direct invasion of the central nervous system by Mycoplasma pneumoniae: A report of two
cases. J Infect Dis 1987;155:482-487.
Fernandez CV, Bortolussi R, Gordon K, et al: Mycoplasma pneumoniae infection associated with central nervous system complications.
J Child Neurol
1993;8:27-31.
Nishimura M, Saida T, Kuroki S, et al: Post-infectious encephalitis with
anti-galactocerebroside antibody subsequent to Mycoplasma pneumoniae infection. J Neurol Sci 1996;140:91-95.

Prevalence of Hypopigmented Maculae and Café-auLait Spots in Idiopathic Epileptic and Healthy
Children

ABSTRACT

hypopigmented maculae and caf6-au-lait spots in idiopathic epileptic children similar to the copresence of skin and central nervous

system lesions in many neurocutaneous syndromes. Second, we

attempted to compare the results with those of healthy children.
Patients and Methods
A total of 210 patients, referred to Hacettepe University Children’s Hospi-

tal’s Department of Pediatric Neurology, were diagnosed as having idiopathic
epilepsy according to the classification of the International League Against
Epilepsy. Patients with epilepsy of organic and metabolic origin and a history of hypoxic-ischemic birth were excluded. To detect the cause of the
epilepsy, cranial computed tomography scans or magnetic resonance
images, serum glucose, calcium, phosphorus, alkaline phosphatase, sodium,
potassium, magnesium, and urine-blood amino acids were examined in all
patients. Patients were examined by a pediatric neurologist completely
naked under daylight, including the genital region, palms of the hands, and
soles of the feet. As well, 2754 healthy children selected randomly from five
primary schools in the province of Malatya were examined by a dermatologist under daylight. Patients who had a history of skin inflammation, burn
scars, pityriasis alba, tinea versicolor, and nevus anemicus on physical
examination and epileptic children were excluded from the study.4 The number, location, and diameter of the lesions both in epileptic and healthy children who had hypopigmented and caf6-au-lait spots were recorded. The
results obtained were evaluated statistically by chi-square test.

The cutaneous lesions and findings related to the central nervous

system are frequently seen concomitantly in many patients. Neu-

Results

rocutaneous syndromes are the most typical examples supporting

The prevalence of hypopigmented maculae and caf6-au-lait spots

this observation. The prevalences of hypopigmented maculae and
café-au-lait spots were investigated in 210 idiopathic epileptic children between the ages of 2 and 17 years and 2754 healthy children
between the ages of 5 and 15 years. In the group of epileptic chil-

dren, hypopigmented maculae and café-au-lait spots were observed
in 30 (14.3%) and 63 (30%) children, respectively. In the group of

healthy children, the prevalence of hypopigmented maculae was
1.6% (44 children) and of café-au-lait spots was 2.83% (78 children). The difference between the two groups was very significant
statistically (
P < .0001). (J Child Neurol 2002;17:57-59).

was

investigated in a total of 210 epileptic children (99 girls and

111 boys) between the ages of 2 and 17 years and in 2754 healthy
children (1338 girls and 1416 boys) between the ages of 5 and 15
years. The hypopigmented maculae were polygonal, ash leaf, and
fingerprint shape. Caf6-au-lait spots were discrete, round or oval,

uniformly hyperpigmented skin patches. Their color varied from
light to dark brown, and the borders were generally smooth and
rarely irregular. Those lesions were classified according to the
number, location, and diameter (Tables 1 to 3). In epileptic children,
the prevalence of hypopigmented maculae was 14.3% (30 children) and of caf6-au-lait spots was 30% (63 children). In healthy
children, the prevalence of hypopigmented maculae was found as
1.6% (44 children) and of caf6-au-lait spots as 2.83% (78 children).
It was found that X2 123.88 and P < .0001 for hypopigmented
=

Hypopigmented or hyperpigmented skin lesions may coexist with

maculae and X2

some central nervous system disorders such as tuberous sclero-

difference between the two groups was very significant statistically.

=

311.89 and P < .0001 for caf6-au-lait spots. The

sis and neurofibromatosis. Symptoms related to the central nervous

system are significant in such neurocutaneous disorders, and the
presence of hypopigmented and hyperpigmented spots is crucial
in the diagnosis of these disorders. 1-3 Our study has two intercon-

Discussion

nected objectives. First, we aimed to determine the prevalence of

tations in the course of some diseases. This condition is seen

Table 1.

Since both the central nervous system and skin have an ectodermal origin embryologically, they can disclose common manifes-

Locations of Hypopigmented Maculae and Caf6-au-Lait Spots in Healthy Group and Epileptic Patients

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