Recurrent isolated cranial nerve palsy associated with Mycoplasma pneumoniae infection

Background: Mycoplasma pneumoniae (Mp) central nervous system complications are reported to be the most common extrapulmonary manifestations occuring in 0.01–4.8% of Mp infected patients.

Case: 9 1/12 year old girl with recurrent isolated unilateral left oculomotorius palsy associated with Mp infection. She bewailed “crossed eyes“ associated with a 2-day history of frontal headache with mild pain in the left eye. Rhinorrhea and cought during the proceeding 2 weeks. The examination excluded meningitis, trauma and neoplasia. High Mp-IgM and -IgG was detectable although CSF PCR for Mp was negative. Despite extensive viral and bacterial investigation, no evidence of any other pathogen was found. Initial MRI shows isolated granulomalike inflammation of the left oculomotorius nerve with brainstem affection. Under antibiotic therapy with clarithromycine for 5 days there was complete remission. Follow up MRI 6 weeks later showed regression of the initial pathological findings. No other lesions were demonstrable. No serological signs of remaining infection with Mp. 3 years ago the patient showed similar symptoms at the left oculomotorius nerve (MRI), high Mp IgM titers, convalescent fall in the titer and clinical restitution under macrolid therapy.

Results: The pecularity of this case is the recurring affection of left oculomotorius nerve linked to an acute infection with Mp. The pathologic mechanism remains unclear but is thought to be the result of direct invasion of the central nervous system or a postinfectious immune response. Mp serology from blood and CSF should be performed early in cases where Mp infection is suspected because increased awareness of this disease entity may facilitate early diagnosis and thereby expedite starting appropriate therapy that may modify the outcome. We propose that these case report represents an example of post-Mp immune mediated central nervous system affection and it seems to be the first report of recurring Mp associated isolated cranial nerve (III) palsy.