persistent mycoplasma IgM/asthma

[mattiemoo]

• 28 yrs old—mild asthma, active/athletic lifestyle
• 28 yrs old—bad URI viral infection, hospitalized, ended up with a blood clot/PE, lupus
• 30 yrs old to 41 yrs—health issues settled down, remained leukopenic, had bronchitis 1-3 times each winter without major issues.  At 40 yrs began cycling and built up to biking 50 miles most weekends.  ANA neg for a few yrs, so autoimmune issues downgraded to “undifferentiated connective tissue disorder”
• 41 yr old—URI virus 10/12.  Since then have been hospitalized 4 times with dyspnea requiring IV steroids. Lab tests indicated initially bordatella IgG was +…considered possibly reactivation of viral infection?  Everything else was negative—blood cultures, legionella, etc. CXR showed hyperinflation.  Work up for PAH was negative via right heart cath.  Immunosuppressed with periodic steroid therapy, leukopenia r/t autoimmune issues, and imuran as a steroid-sparing agent.  July 2013 tested positive for mycoplasma IgM (serum).  Had bronchoscopy, testing was negative.  
• Meds—LABA and inhaled corticosteroid.  PFT’s indicated higher than predicted values for most measurements and some air trapping.  High resolution CT indicated inflammation and mild bronchieactasis, but no infiltrates or consolidations.
• Early 2014—Immunology testing indicated IgG subset 3 deficiency and possible hypogammaglobunemia.  Also remained + for mycoplasma IgM since July 2013. After 7 months of antibiotic tx, stopped d/t side effects.  SOB, chest pain persist.
• Currently anticipate additional immunology testing soon.  Right now don’t quite qualify for insurance coverage for IVIG therapy.  After polysaccharide vaccine test, titers went up.  

Questions—is it possible that this is consistent with persistent mycoplasma infection or colonization? If so, would it get better with IVIG? What other testing/tx should be considered?

Thank you!!

[David Tinkelman, M.D.]

Briefly, your lungs may be chronically infected with mycoplasma and, given that possibility, long term therapy with macrolides would be reasonable.  Biopsy and PCR would be required for confirmation.  Much of what you cite suggest that your disease is progressive and the demonstration of bronchiectasis would be consistent with that premise.

Yours is a very complex situation and it is not possible for me to provide a detailed response, given the constraints of this forum.  Given the many factors contributing to your sustained illness a proper assessment of everything that is going on will require a comprehensive, in person evaluation at an institution whose physicians have the expertise required for diagnosis and treatment.

I suggest that you and your physicians consider seeking consultation at one of the following institutions:  The University of Pittsburgh Medical Center – Dr. Sally Wenzel; Duke University Medical Center –Dr. Monica Kraft or, National Jewish Health in Denver Colorado – Dr. Richard Martin.  It would be wise for you to seek such assistance, without further delay.

Good luck

[mattiemoo]

One more question, would additional antibiotic therapy be warranted? I was on Zithromax for the 7 mos...initially at 250 mg, then 500 mg daily.  I had heard the mycoplasma can cause significant, difficult to control asthma exacerbations.  

My quality of life has diminished significantly ever since Oct 2012.  Where I was able to enjoy distance cycling, I now have SOB every day despite multiple respiratory meds and periodic high dose steroids.  Luckily I can still work.  

Any advice you can offer is greatly appreciated!  Thank you!!