Acute Mycoplasma pneumoniae infection presenting as cholestatic hepatitis.

A previously healthy 35-year-old man presented with fever, coughs, and jaundice. After flu-like symptoms for 2 weeks, the patient developed mild jaundice and high fever. On admission to our hospital, the physical examination revealed scleral jaundice and was otherwise unremarkable. Body temperature was 39.5°C. Chest X ray showed a patchy dense infiltration of the right lower lobe. Abdominal ultrasound showed small bilateral pleural effusions and minimal ascites. Abnormal laboratory findings on admission included alanine aminotransferase (ALT), 79 U/liter (normal, 23 U/liter); bilirubin, 2.8 mg/dl (normal, 1.2 mg/dl); alkaline phosphatase, 753 U/liter (normal, 200 U/liter); serum albumin, 2.7 g/dl (normal, 3.5 g/dl); and international normalized ratio, 2.1 (normal, 1.0). Known causes of acute hepatitis were excluded: anti-hepatitis A virus immunoglobulin M (IgM), negative; HBsAg and anti-HBc, negative; anti-HCV, negative; anti-nuclear antibodies, 1:10; antimitochondrial antibodies, negative; antismooth-muscle antibodies, negative; and no evidence for acute infection with herpes simplex virus, cytomegalovirus, or Epstein-Barr virus. Further, there was no evidence for hemochromatosis or Wilson s disease. Alcoholic or drug-induced hepatitis was excluded by the patient s history. Further serologic workup revealed acute infection with Mycoplasma pneumoniae (IgG enzyme immunoassay [EIA], 263 U/ml; IgA EIA, 162 U/ml; IgM EIA, 338 U/ml (titers of 64 U/ml are considered positive). Antibiotic therapy was started with cefuroxime given intravenously; 1 day later, therapy was changed to clarithromycin (500 mg orally twice daily for 3 weeks), resulting in a quick improvement of the patient s clinical condition. Ten days after the initiation of the antibiotic therapy, the pulmonary infiltration had disappeared. Liver function tests also improved quickly (Fig. 1), except for the ALT elevation, which persisted about 6 months before returning to normal levels.