P2.242: Mycoplasma Induced Opsoclonus-Myoclonus Syndrome in a Pediatric Patient

Introduction: Opsoclonus myoclonus syndrome (OMS) is a nonfatal syndrome where patients present with chaotic eye movement, muscle jerks, and ataxia. The etiology of OMS is unclear, but about half are caused by neuroblastoma, and half by infectious agents. Mycoplasma pneumoniae is the leading cause of atypical pneumonia in the United States, and can cause CNS manifestations in 1 of 1000 patients, with few cases showing OMS. OMS is rare with an incidence of 0.18 per million per year. No therapeutic guidelines have been established due to lack of randomized control trials. Past cases of OMS were treated with immunotherapies, such as steroids, adrenocorticotropic hormone, and IVIG for neurologic symptoms. We present a rare case of mycoplasma induced OMS in a pediatric patient that improved with treatment of mycoplasma pneumonia with doxycycline.

Case Description: Patient is a previously healthy 9-year-old female who presented with fever and generalized muscle aches for two weeks with new symptoms of vomiting and abdominal pain. On presentation, patient was noted to have rotary nystagmus, crackles in her left lower lobe, nuchal rigidity, and positive Kernig’s sign. She was admitted to the pediatric floor for evaluation and management. Labs positive for mycoplasma, CMV IgM, and EBV IgM. Chest radiograph revealed left lower lobe opacity. CT head and MRI head showed no significant findings. Lumbar puncture was done and CSF culture and PCR were negative, but WBC count was elevated. Based on chest radiograph, respiratory PCR, and opsoclonus symptoms, we chose to treat the patient for mycoplasma infection with CNS involvement. Patient was treated with ceftriaxone, azithromycin, and doxycycline for 14 days total. Patient had complete resolution of symptoms after 1 month.

Discussion: To our knowledge, there are no therapeutic guidelines for OMS secondary to infection, but previous cases were treated with immunotherapies such as steroids and IVIG. We propose antibiotics with good CSF penetration as a viable treatment option in our case. Etiology of CNS manifestations of mycoplasma pneumoniae is unclear, but it has been proposed that it is via direct damage of CNS by bacteria or indirect damage by antibodies produced against bacteria that attack myelin glycolipids due to molecular mimicry. Treatment with doxycycline resolving the CNS manifestation supports the theory of direct damage vs indirect damage in our case.

Conclusion: Despite the inability of the CSF to be assessed for mycoplasma, the patient’s symptoms, CSF pleocytosis, and respiratory PCR indicated mycoplasma induced OMS in our patient. Due to neurologic symptoms, we chose to treat the patient with doxycycline, as tetracyclines have better CSF penetration than macrolides. Past cases have shown resolution of OMS symptoms with immunotherapies, but we present an alternative treatment with antimicrobials with CSF penetration due to prevention of these agents preventing direct damage to CNS.