Mycoplasma -Related Acute Hemorrhagic Leukoencephalomyelitis

Figure

a) Spinal magnet resonance imaging (3 Tesla) following clinical deterioration (tetraparesis, loss of sight, and respiratory failure). Sagittal thin-slice (2 mm) T2 turbo-spin-echo sequence. Cervical and upper thoracic spinal cord: long-segment myelitis (white arrows) of cervical vertebra (C) 2 to thoracic vertebra 4, intramedullary hemorrhage at the level of C7 (arrow with dashed line). b) Cranial magnetic resonance imaging (3 Tesla) following a clinical deterioration (tetraparesis, loss of sight, and respiratory failure). Transverse SWI sequence. Bi-occipital intralesional blood degradation products/hemorrhages in the white matter (arrowheads).

A 19-year-old male presented with new-onset sensory impairment in the right leg following a respiratory infection 10 days previously. Within 2 h, acute sensorimotor paraplegia and overflow incontinence developed. Magnetic resonance imaging revealed long-segment myelitis (fifth cervical vertebra to ninth thoracic vertebra), while cerebrospinal fluid analysis showed lymphocytic pleocytosis (43 cells/μL). Despite immediate treatment with ceftriaxone, aciclovir, and 1 g methylprednisolone, bilateral loss of sight, tetraparesis, dysphagia, and the need for artificial ventilation developed within hours. On magnetic resonance imaging (MRI), the myelitis was now ascending, almost reaching the medulla oblongata, in addition to which, bi-occipital increases in signal intensity due to hemorrhagic transformation were seen. Based on positive Mycoplasma pneumoniae serology (IgG/IgA/IgM in serum/cerebrospinal fluid) and polymerase chain reaction in the bronchial aspirate, we assumed a diagnosis of fulminant Mycoplasma pneumoniae-related acute hemorrhagic leukoencephalomyelitis. A treatment escalation (2 g methylprednisolone/day, IVIG, cyclophosphamide, immunoadsorption, and doxycyclin therapy) resulted in a slow and incomplete clinical improvement and regression of the MRI lesions. Acute CNS symptoms following a pulmonary infection and increased signal intensity due to hemorrhagic transformation on magnetic resonance imaging should prompt suspicion of acute hemorrhagic leukoencephalomyelitis.

Dr. med. Mathias Fousse, Dr. med. Jakob Stögbauer, Klinik für Neurologie, Universitätsklinikum des Saarlandes, Homburg, [e-mail]

Dr. med. Michael Kettner, Klinik für Neuroradiologie, Universitätsklinikum des Saarlandes, Homburg

Conflict of interest statement: The authors state that no conflict of interest exists.

Translated from the original German by Christine Rye.

Cite this as: Fousse M, Kettner M, Stögbauer J: Mycoplasma-related acute hemorrhagic leukoencephalomyelitis. Dtsch Arztebl Int 2025; 122: 347. DOI: 10.3238/arztebl.m2024.0237