Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Mycoplasmal Pneumonia
Mycoplasmal pneumonia is an acute infection of the lungs characterized by cough and fever. Symptoms are generally milder than those of bacterial pneumonia. Mycoplasmal pneumonia is the so-called walking pneumonia.
I. Etiology: Mycoplasma pneumoniae, the smallest known pathogen that can live outside of cells
II. Incidence
A. The most common cause of pneumonia in school-age children and adolescents, occurring in about 5 per 1,000 school-age children annually
B. The most common cause of nonbacterial pneumonias in all age groups
C. Peak incidence is in the fall and early winter, but it does occur sporadically year round.
III. Incubation period: 14 to 21 days
IV. Subjective data
A. Insidious onset
B. Headache
C. Chills
D. Low-grade temperature
E. Malaise
F. Cough: Initially nonproductive, dry, hacking
G. Sore throat
H. Occasional ear pain
I. Anorexia
J. History of exposure to mycoplasmal pneumonia or other respiratory illnesses (pharyngitis, cough, earache)
V. Objective data
A. Fever variable, generally low-grade
B. Lethargy
C. Child does not appear particularly ill.
D. Chest findings are variable.
1. Decreased percussion (rare)
2. Decreased tactile and vocal fremitus (rare)
3. Diminished breath sounds
4. Few scattered rales or crackles to severe bilateral involvement
5. Expiratory wheezing may be heard.
6. Lower lobes are involved more frequently than are upper lobes.
E. Occasionally, inflamed tympanic membranes or bullous myringitis
F. X-ray findings are variable but are more extensive than would be expected from clinical signs.
1. Increase in bronchovascular markings.
2. Unilateral peribronchial infiltrate or lobar consolidation, although multilobe involvement does occur
G. Laboratory test
1. Cold agglutinins are helpful in diagnosis but are nonspecific.
a. Cold agglutinins are seen in influenza, infectious mononucleosis, and other nonbacterial infections.
b. Cold agglutinin titer develops in about 50% of children with mycoplasmal pneumonia.
c. Titer rises 8 to 10 days after onset and peaks in 12 to 25 days.
d. Titer of 1:256 is suggestive of Mycoplasma.
2. Culture and serologic testing take too long to be useful in determining treatment.
VI. Assessment
A. Diagnosis of M. pneumoniae is based on typical features, generally an informed clinical judgment.
1. Patient age
2. Patient nontoxic
3. History of slowly evolving symptoms; indolent course, fatigue, cough
4. Fine rales heard on auscultation
5. Low-grade fever
B. Differential diagnosis. Mycoplasmal pneumonia cannot be distinguished from other atypical pneumonias by clinical signs (see also Differential Diagnosis of Viral Croup, Bronchiolitis, Pneumonia, and Bronchitis).
VII. Plan
A. Antibiotics: M. pneumoniae is the predominant cause of antibioticresponsive pneumonia in the school-age child. Therapy should be instituted if the diagnosis is suspected.
1. Erythromycin, 40 to 50 mg/kg/d in 4 divided doses (>20 kg, 250 mg qid) or zithromax if GI upset
or
2. Tetracycline, in children 12 years of age and above: 250 mg qid or
3. Biaxin, 15 mg/kg/d in divided doses every 12 hours (>33 kg,
250 mg bid); drug of choice if uncertain whether mycoplasmal or pneumococcal pneumonia
B. Acetaminophen for temperature over 101F (38.3C); use sparingly,
because temperature in part indicates response to pharmacologic therapy.
C. Rest
D. Increased fluids
E. Cool mist vaporizer
F. Cough suppressant as indicated (Benylin Cough Syrup)
VIII. Education
A. Give antibiotic for 10 full days.
B. Antibiotics shorten the course of the illness but generally do not produce a dramatic response as in bacterial pneumonias.
C. Biaxin or erythromycin can be given with or without food.
D. Do not give antihistamines.
E. Encourage fluids to help keep secretions from thickening.
F. Transmitted directly by oral and nasal secretions and indirectly by contaminated articles.
G. Use careful handwashing technique.
H. An attack probably confers immunity for a year or longer; no permanent immunity is conferred.
I. If child has trouble coughing up secretions, place him or her prone with head lower than feet, and percuss chest with cupped hands.
J. Call immediately if child has difficulty breathing or becomes restless or anxious: These symptoms are indicative of anoxia.
K. Duration of illness is about 2 weeks. A night cough persists longer.
L. Family members and close contacts are at risk for Mycoplasma
infection.
IX. Follow-up
A. Call back daily until improvement is noted.
B. Recheck if no improvement in 48 hours.
C. Recheck in 10 days. Occasionally pneumonia may recrudesce, and re-treatment may be necessary.
D. Call if any question of sensitivity to medication.
E. Repeat chest X-ray in 2 weeks if
1. Any signs of respiratory difficulty persist
2. History of pneumonia
3. Child has cardiopulmonary disease
4. Chest X-ray may be abnormal for 4 to 6 weeks after pneumonia.
X. Complications: Rare
XI. Consultation/referral
A. Infants
B. Toxic child
C. Respiratory distress or cyanosis
D. No clinical improvement after 48 hours of therapy