Exploring the pathogenetic mechanisms of <em>Mycoplasma</em> <em>pneumoniae</em> (Review)

Georgakopoulou,Vasiliki Epameinondas; Lempesis,Ioannis G.; Sklapani,Pagona; Trakas,Nikolaos; Spandidos,Demetrios A.

doi:10.3892/etm.2024.12559

July-2024 Volume 28 Issue 1

Full Size Image

Journals

International Journal of Molecular Medicine

International Journal of Molecular Medicine is an international journal devoted to molecular mechanisms of human disease.

International Journal of Oncology

International Journal of Oncology is an international journal devoted to oncology research and cancer treatment.

Molecular Medicine Reports

Covers molecular medicine topics such as pharmacology, pathology, genetics, neuroscience, infectious diseases, molecular cardiology, and molecular surgery.

Oncology Reports

Oncology Reports is an international journal devoted to fundamental and applied research in Oncology.

Experimental and Therapeutic Medicine

Experimental and Therapeutic Medicine is an international journal devoted to laboratory and clinical medicine.

Oncology Letters

Oncology Letters is an international journal devoted to Experimental and Clinical Oncology.

Biomedical Reports

Explores a wide range of biological and medical fields, including pharmacology, genetics, microbiology, neuroscience, and molecular cardiology.

Molecular and Clinical Oncology

International journal addressing all aspects of oncology research, from tumorigenesis and oncogenes to chemotherapy and metastasis.

World Academy of Sciences Journal

Multidisciplinary open-access journal spanning biochemistry, genetics, neuroscience, environmental health, and synthetic biology.

International Journal of Functional Nutrition

Open-access journal combining biochemistry, pharmacology, immunology, and genetics to advance health through functional nutrition.

International Journal of Epigenetics

Publishes open-access research on using epigenetics to advance understanding and treatment of human disease.

Medicine International

An International Open Access Journal Devoted to General Medicine.

July-2024 Volume 28 Issue 1

Full Size Image

Review Open Access

Exploring the pathogenetic mechanisms of Mycoplasma pneumoniae (Review)

Authors:
- Vasiliki Epameinondas Georgakopoulou
- Ioannis G. Lempesis
- Pagona Sklapani
- Nikolaos Trakas
- Demetrios A. Spandidos
View Affiliations / Copyright

Affiliations: Department of Pathophysiology, Laiko General Hospital, National and Kapodisttrian University of Athens, 11527 Athens, Greece, Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece, Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece

Copyright: © Georgakopoulou et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
Article Number: 271
|
Published online on: April 30, 2024

https://doi.org/10.3892/etm.2024.12559
Expand metrics +

Abstract

Mycoplasmas, the smallest self‑replicating prokaryotes without a cell wall, are the most prevalent and extensively studied species in humans. They significantly contribute to chronic respiratory tract illnesses and pneumonia, with children and adolescents being particularly vulnerable. Mycoplasma pneumoniae (M. pneumoniae) infections typically tend to be self‑limiting and mild but can progress to severe or even life‑threatening conditions in certain individuals. Extrapulmonary effects often occur without pneumonia, and both intrapulmonary and extrapulmonary complications operate through separate pathological mechanisms. The indirect immune‑mediated damage of the immune system, vascular blockages brought on by vasculitis or thrombosis and direct harm from invasion or locally induced inflammatory cytokines are potential causes of extrapulmonary manifestations due to M. pneumoniae. Proteins associated with adhesion serve as the primary factor crucial for the pathogenicity of M. pneumoniae, relying on a specialized polarized terminal attachment organelle. The type and density of these host receptors significantly impact the adhesion and movement of M. pneumoniae, subsequently influencing the pathogenic mechanism and infection outcomes. Adjacent proteins are crucial for the proper assembly of the attachment organelle, with variations in the genetic domains of P1, P40 and P90 surfaces contributing to the variability of clinical symptoms and offering new avenues for developing vaccines against M. pneumoniae infections. M. pneumoniae causes oxidative stress within respiratory tract epithelial cells by adhering to host cells and releasing hydrogen peroxide and superoxide radicals. This oxidative stress enhances the vulnerability of host cells to harm induced by oxygen molecules. The lack of superoxide dismutase and catalase of bacteria allows it to hinder the catalase activity of the host cell, leading to the reduced breakdown of peroxides. Lung macrophages play a significant role in managing M. pneumoniae infection, identifying it via Toll‑like receptor 2 and initiating the myeloid differentiation primary response gene 88‑nuclear factor κΒ signaling cascade. However, the precise mechanisms enabling M. pneumoniae to evade intracellular host defenses remain unknown, necessitating further exploration of the pathways involved in intracellular survival. The present comprehensive review delves into the pathogenesis of M. pneumoniae infection within the pulmonary system and into extrapulmonary areas, outlining its impact.

View Figures

View References

1	Zhang L, Lai M, Ai T, Liao H, Huang Y, Zhang Y, Liu Y, Wang L and Hu J: Analysis of Mycoplasma pneumoniae infection among children with respiratory tract infections in hospital in Chengdu from 2014 to 2020. Transl Pediatr. 10:990–997. 2021.PubMed/NCBI View Article : Google Scholar
2	Bajantri B, Venkatram S and Diaz-Fuentes G: Mycoplasma pneumoniae: A potentially severe infection. J Clin Med Res. 10:535–544. 2018.PubMed/NCBI View Article : Google Scholar
3	Lanao AE, Chakraborty RK and Pearson-Shaver AL: Mycoplasma. Infections. In: StatPearls. StatPearls Publishing, Treasure Island, FL, 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536927/.
4	Kutty PK, Jain S, Taylor TH, Bramley AM, Diaz MH, Ampofo K, Arnold SR, Williams DJ, Edwards KM, McCullers JA, et al: Mycoplasma pneumoniae among children hospitalized with community-acquired pneumonia. Clin Infect Dis. 68:5–12. 2019.PubMed/NCBI View Article : Google Scholar
5	Waites KB, Xiao L, Liu Y, Balish MF and Atkinson TP: Mycoplasma pneumoniae from the respiratory tract and beyond. Clin Microbiol Rev. 30:747–809. 2017.PubMed/NCBI View Article : Google Scholar
6	Jiang Z, Li S, Zhu C, Zhou R and Leung PHM: Mycoplasma pneumoniae infections: Pathogenesis and vaccine development. Pathogens. 10(119)2021.PubMed/NCBI View Article : Google Scholar
7	Waites KB, Xiao L, Paralanov V, Viscardi RM and Glass JI: Molecular methods for the detection of Mycoplasma and ureaplasma infections in humans: A paper from the 2011 William beaumont hospital symposium on molecular pathology. J Mol Diagn. 14:437–450. 2012.PubMed/NCBI View Article : Google Scholar
8	Poddighe D: Extra-pulmonary diseases related to Mycoplasma pneumoniae in children: Recent insights into the pathogenesis. Curr Opin Rheumatol. 30:380–387. 2018.PubMed/NCBI View Article : Google Scholar
9	He J, Liu M, Ye Z, Tan T, Liu X, You X, Zeng Y and Wu Y: Insights into the pathogenesis of Mycoplasma pneumoniae (review). Mol Med Rep. 14:4030–4036. 2016.PubMed/NCBI View Article : Google Scholar
10	Yamamoto T, Kida Y and Kuwano K: Mycoplasma pneumoniae protects infected epithelial cells from hydrogen peroxide-induced cell detachment. Cell Microbiol. 21(e13015)2019.PubMed/NCBI View Article : Google Scholar
11	Nakane D, Murata K, Kenri T, Shibayama K and Nishizaka T: Molecular ruler of the attachment organelle in Mycoplasma pneumoniae. PLoS Pathog. 17(e1009621)2021.PubMed/NCBI View Article : Google Scholar
12	Williams CR, Chen L, Sheppard ES, Chopra P, Locklin J, Boons GJ and Krause DC: Distinct Mycoplasma pneumoniae interactions with sulfated and sialylated receptors. Infect Immun. 88:e00392–20. 2020.PubMed/NCBI View Article : Google Scholar
13	Williams CR, Chen L, Driver AD, Arnold EA, Sheppard ES, Locklin J and Krause DC: Sialylated receptor setting influences Mycoplasma pneumoniae attachment and gliding motility. Mol Microbiol. 109:735–744. 2018.PubMed/NCBI View Article : Google Scholar
14	Chaudhry R, Ghosh A and Chandolia A: Pathogenesis of Mycoplasma pneumoniae: An update. Indian J Med Microbiol. 34:7–16. 2016.PubMed/NCBI View Article : Google Scholar
15	Miyata M and Hamaguchi T: Integrated information and prospects for gliding mechanism of the pathogenic bacterium Mycoplasma pneumoniae. Front Microbiol. 7(960)2016.PubMed/NCBI View Article : Google Scholar
16	Widjaja M, Berry IJ, Jarocki VM, Padula MP, Dumke R and Djordjevic SP: Cell surface processing of the P1 adhesin of Mycoplasma pneumoniae identifies novel domains that bind host molecules. Sci Rep. 10(6384)2020.PubMed/NCBI View Article : Google Scholar
17	Romero-Arroyo CE, Jordan J, Peacock SJ, Willby MJ, Farmer MA and Krause DC: Mycoplasma pneumoniae protein P30 is required for cytadherence and associated with proper cell development. J Bacteriol. 181:1079–1087. 1999.PubMed/NCBI View Article : Google Scholar
18	Tabassum I, Chaudhry R, Chourasia BK and Malhotra P: Identification of an N-terminal 27 kDa fragment of Mycoplasma pneumoniae P116 protein as specific immunogen in M. pneumoniae infections. BMC Infect Dis. 10(350)2010.PubMed/NCBI View Article : Google Scholar
19	Fan L, Li D, Zhang L, Hao C, Sun H, Shao X, Xu J and Chen Z: Pediatric clinical features of Mycoplasma pneumoniae infection are associated with bacterial P1 genotype. Exp Ther Med. 14:1892–1898. 2017.PubMed/NCBI View Article : Google Scholar
20	Sun H, Xue G, Yan C, Li S, Zhao H, Feng Y and Wang L: Changes in molecular characteristics of Mycoplasma pneumoniae in clinical specimens from children in Beijing between 2003 and 2015. PLoS One. 12(e0170253)2017.PubMed/NCBI View Article : Google Scholar
21	Xue G, Cao L, Wang L, Zhao H, Feng Y, Ma L and Sun H: Evaluation of P1 adhesin epitopes for the serodiagnosis of Mycoplasma pneumoniae infections. FEMS Microbiol Lett. 340:86–92. 2013.PubMed/NCBI View Article : Google Scholar
22	Meng YL, Wang WM, Lv DD, An QX, Lu WH, Wang X and Tang G: The effect of Platycodin D on the expression of cytoadherence proteins P1 and P30 in Mycoplasma pneumoniae models. Environ Toxicol Pharmacol. 49:188–193. 2017.PubMed/NCBI View Article : Google Scholar
23	Rodman Berlot J, Krivec U, Praprotnik M, Mrvič T, Kogoj R and Keše D: Clinical characteristics of infections caused by Mycoplasma pneumoniae P1 genotypes in children. Eur J Clin Microbiol Infect Dis. 37:1265–1272. 2018.PubMed/NCBI View Article : Google Scholar
24	Zhu C, Wu Y, Chen S, Yu M, Zeng Y, You X, Xiao J and Wang S: Protective immune responses in mice induced by intramuscular and intranasal immunization with a Mycoplasma pneumoniae P1C DNA vaccine. Can J Microbiol. 58:644–652. 2012.PubMed/NCBI View Article : Google Scholar
25	Varshney AK, Chaudhry R, Kabra SK and Malhotra P: Cloning, expression, and immunological characterization of the P30 protein of Mycoplasma pneumoniae. Clin Vaccine Immunol. 15:215–120. 2008.PubMed/NCBI View Article : Google Scholar
26	Blötz C, Singh N, Dumke R and Stülke J: Characterization of an immunoglobulin binding protein (IbpM) from Mycoplasma pneumoniae. Front Microbiol. 11(685)2020.PubMed/NCBI View Article : Google Scholar
27	Szczepanek SM, Majumder S, Sheppard ES, Liao X, Rood D, Tulman ER, Wyand S, Krause DC, Silbart LK and Geary SJ: Vaccination of BALB/c mice with an avirulent Mycoplasma pneumoniae P30 mutant results in disease exacerbation upon challenge with a virulent strain. Infect Immun. 80:1007–1014. 2012.PubMed/NCBI View Article : Google Scholar
28	Rathore JS and Wang Y: Protective role of Th17 cells in pulmonary infection. Vaccine. 34:1504–1514. 2016.PubMed/NCBI View Article : Google Scholar
29	Yang J, Sundrud MS, Skepner J and Yamagata T: Targeting Th17 cells in autoimmune diseases. Trends Pharmacol Sci. 35:493–500. 2014.PubMed/NCBI View Article : Google Scholar
30	Hausner M, Schamberger A, Naumann W, Jacobs E and Dumke R: Development of protective anti-Mycoplasma pneumoniae antibodies after immunization of guinea pigs with the combination of a P1-P30 chimeric recombinant protein and chitosan. Microb Pathog. 64:23–32. 2013.PubMed/NCBI View Article : Google Scholar
31	Svenstrup HF, Nielsen PK, Drasbek M, Birkelund S and Christiansen G: Adhesion and inhibition assay of Mycoplasma genitalium and M. pneumoniae by immunofluorescence microscopy. J Med Microbiol. 51:361–373. 2002.PubMed/NCBI View Article : Google Scholar
32	Duffy MF, Walker ID and Browning GF: The immunoreactive 116 kDa surface protein of Mycoplasma pneumoniae is encoded in an operon. Microbiology (Reading). 143:3391–3402. 1997.PubMed/NCBI View Article : Google Scholar
33	Vizarraga D, Kawamoto A, Matsumoto U, Illanes R, Pérez-Luque R, Martín J, Mazzolini R, Bierge P, Pich OQ, Espasa M, et al: Immunodominant proteins P1 and P40/P90 from human pathogen Mycoplasma pneumoniae. Nat Commun. 11(5188)2020.PubMed/NCBI View Article : Google Scholar
34	Feng M, Schaff AC, Cuadra Aruguete SA, Riggs HE, Distelhorst SL and Balish MF: Development of Mycoplasma pneumoniae biofilms in vitro and the limited role of motility. Int J Med Microbiol. 324:324–334. 2018.PubMed/NCBI View Article : Google Scholar
35	Hu J, Ye Y, Chen X, Xiong L, Xie W and Liu P: Insight into the pathogenic mechanism of Mycoplasma pneumoniae. Curr Microbiol. 80(14)2022.PubMed/NCBI View Article : Google Scholar
36	Yang J, Hooper WC, Phillips DJ and Talkington DF: Cytokines in Mycoplasma pneumoniae infections. Cytokine Growth Factor Rev. 15:157–168. 2004.PubMed/NCBI View Article : Google Scholar
37	Balasubramanian S, Pandranki L, Maupin S, Ramasamy K, Taylor AB, Hart PJ, Baseman JB and Kannan TR: Disulfide bond of Mycoplasma pneumoniae community-acquired respiratory distress syndrome toxin is essential to maintain the ADP-ribosylating and vacuolating activities. Cell Microbiol. 21(e13032)2019.PubMed/NCBI View Article : Google Scholar
38	Ramasamy K, Balasubramanian S, Kirkpatrick A, Szabo D, Pandranki L, Baseman JB and Kannan TR: Mycoplasma pneumoniae CARDS toxin exploits host cell endosomal acidic pH and vacuolar ATPase proton pump to execute its biological activities. Sci Rep. 11(11571)2021.PubMed/NCBI View Article : Google Scholar
39	Blötz C and Stülke J: Glycerol metabolism and its implication in virulence in Mycoplasma. FEMS Microbiol Rev. 41:640–652. 2017.PubMed/NCBI View Article : Google Scholar
40	Schumacher M, Nicholson P, Stoffel MH, Chandran S, D'Mello A, Ma L, Vashee S, Jores J and Labroussaa F: Evidence for the cytoplasmic localization of the L-α-glycerophosphate oxidase in members of the ‘Mycoplasma mycoides cluster’. Front Microbiol. 10(1344)2019.PubMed/NCBI View Article : Google Scholar
41	Waites KB, Balish MF and Atkinson TP: New insights into the pathogenesis and detection of Mycoplasma pneumoniae infections. Future Microbiol. 3:635–648. 2008.PubMed/NCBI View Article : Google Scholar
42	Segovia JA, Chang TH, Winter VT, Coalson JJ, Cagle MP, Pandranki L, Bose S, Baseman JB and Kannan TR: NLRP3 is a critical regulator of inflammation and innate immune cell response during Mycoplasma pneumoniae infection. Infect Immun. 86:e00548–17. 2017.PubMed/NCBI View Article : Google Scholar
43	Shimizu T, Kimura Y, Kida Y, Kuwano K, Tachibana M, Hashino M and Watarai M: Cytadherence of Mycoplasma pneumoniae induces inflammatory responses through autophagy and toll-like receptor 4. Infect Immun. 82:3076–3086. 2014.PubMed/NCBI View Article : Google Scholar
44	Li S, Xue G, Zhao H, Feng Y, Yan C, Cui J and Sun H: The Mycoplasma pneumoniae HapE alters the cytokine profile and growth of human bronchial epithelial cells. Biosci Rep. 39(BSR20182201)2019.PubMed/NCBI View Article : Google Scholar
45	Luo H, He J, Qin L, Chen Y, Chen L, Li R, Zeng Y, Zhu C, You X and Wu Y: Mycoplasma pneumoniae lipids license TLR-4 for activation of NLRP3 inflammasome and autophagy to evoke a proinflammatory response. Clin Exp Immunol. 203:66–79. 2021.PubMed/NCBI View Article : Google Scholar
46	Mara AB, Gavitt TD, Tulman ER, Geary SJ and Szczepanek SM: Lipid moieties of Mycoplasma pneumoniae lipoproteins are the causative factor of vaccine-enhanced disease. NPJ Vaccines. 5(31)2020.PubMed/NCBI View Article : Google Scholar
47	Narita M: Classification of extrapulmonary manifestations due to Mycoplasma pneumoniae Infection on the basis of possible pathogenesis. Front Microbiol. 7(23)2016.PubMed/NCBI View Article : Google Scholar
48	Li G, Fan L, Wang Y, Huang L, Wang M, Zhu C, Hao C, Ji W, Liang H, Yan Y and Chen Z: High co-expression of TNF-α and CARDS toxin is a good predictor for refractory Mycoplasma pneumoniae pneumonia. Mol Med. 25(38)2019.PubMed/NCBI View Article : Google Scholar
49	Zhao Y, Ma G and Yang X: HDAC5 promotes Mycoplasma pneumoniae-induced inflammation in macrophages through NF-κB activation. Life Sci. 221:13–19. 2019.PubMed/NCBI View Article : Google Scholar
50	Hakim MS, Annisa L, Jariah ROA and Vink C: The mechanisms underlying antigenic variation and maintenance of genomic integrity in Mycoplasma pneumoniae and Mycoplasma genitalium. Arch Microbiol. 203:413–429. 2021.PubMed/NCBI View Article : Google Scholar
51	Kenri T, Kawakita Y, Kudo H, Matsumoto U, Mori S, Furukawa Y, Tahara YO, Shibayama K, Hayashi Y, Arai M and Miyata M: Production and characterization of recombinant P1 adhesin essential for adhesion, gliding, and antigenic variation in the human pathogenic bacterium Mycoplasma pneumoniae. Biochem Biophys Res Commun. 508:1050–1055. 2019.PubMed/NCBI View Article : Google Scholar
52	Lee D, Lal NK, Lin ZD, Ma S, Liu J, Castro B, Toruño T, Dinesh-Kumar SP and Coaker G: Regulation of reactive oxygen species during plant immunity through phosphorylation and ubiquitination of RBOHD. Nat Commun. 11(1838)2020.PubMed/NCBI View Article : Google Scholar
53	Chen LS, Li C, You XX, Lin YW and Wu YM: The mpn668 gene of Mycoplasma pneumoniae encodes a novel organic hydroperoxide resistance protein. Int J Med Microbiol. 308:776–783. 2018.PubMed/NCBI View Article : Google Scholar
54	Yu Y, Wang J, Han R, Wang L, Zhang L, Zhang AY, Xin J, Li S, Zeng Y, Shao G, et al: Mycoplasma hyopneumoniae evades complement activation by binding to factor H via elongation factor thermo unstable (EF-Tu). Virulence. 11:1059–1074. 2020.PubMed/NCBI View Article : Google Scholar
55	Waites KB and Talkington DF: Mycoplasma pneumoniae and its role as a human pathogen. Clin Microbiol Rev. 17:697–728, table of contents. 2004.PubMed/NCBI View Article : Google Scholar
56	Mirijello A, La Marca A, D'Errico MM, Curci S, Vendemiale G, Grandone E and De Cosmo S: Venous thromboembolism during Mycoplasma pneumoniae infection: Case report and review of the literature. Eur Rev Med Pharmacol Sci. 24:10061–10068. 2020.PubMed/NCBI View Article : Google Scholar
57	Choi SY, Choi YJ, Choi JH and Choi KD: Isolated optic neuritis associated with Mycoplasma pneumoniae infection: Report of two cases and literature review. Neurol Sci. 38:1323–1327. 2017.PubMed/NCBI View Article : Google Scholar
58	Song WJ, Kang B, Lee HP, Cho J, Lee HJ and Choe YH: Pediatric Mycoplasma pneumoniae infection presenting with acute cholestatic hepatitis and other extrapulmonary manifestations in the absence of pneumonia. Pediatr Gastroenterol Hepatol Nutr. 20:124–129. 2017.PubMed/NCBI View Article : Google Scholar
59	Mitsuo N: Classifcation of extrapulmonary manifestations due to Mycoplasma pneumoniae infection on the basis of possible pathogenesis. Fron Microbiol. 7(23)2016.PubMed/NCBI View Article : Google Scholar
60	Wang Z, Sun J, Liu Y and Wang Y: Impact of atopy on the severity and extrapulmonary manifestations of childhood Mycoplasma pneumoniae pneumonia. J Clin Lab Anal. 33(e22887)2019.PubMed/NCBI View Article : Google Scholar
61	Naghib M, Hatam-Jahromi M, Niktab M, Ahmadi R and Kariminik A: Mycoplasma pneumoniae and toll-like receptors: A mutual avenue. Allergol Immunopathol (Madr). 46:508–513. 2018.PubMed/NCBI View Article : Google Scholar
62	Fink CG, Sillis M, Read SJ, Butler L and Pike M: Neurological disease associated with Mycoplasma pneumoniae infection. PCR evidence against a direct invasive mechanism. Clin Mol Pathol. 48:M51–M54. 1995.PubMed/NCBI View Article : Google Scholar
63	Shimizu T, Kida Y and Kuwano K: A dipalmitoylated lipoprotein from Mycoplasma pneumoniae activates NF-kappa B through TLR1, TLR2, and TLR6. J Immunol. 175:4641–4646. 2005.PubMed/NCBI View Article : Google Scholar
64	Meyer Sauteur PM, de Bruijn ACJM, Graça C, Tio-Gillen AP, Estevão SC, Hoogenboezem T, Hendriks RW, Berger C, Jacobs BC, van Rossum AMC, et al: Antibodies to protein but not glycolipid structures are important for host defense against Mycoplasma pneumoniae. Infect Immun. 87:e00663–18. 2019.PubMed/NCBI View Article : Google Scholar
65	Widén J, Jönsson G and Karlsson U: Mycoplasma pneumonia with severe cold agglutinin hemolysis, thrombocytosis, leukemoid reaction and acute renal failure. IDCases. 31(e01689)2023.PubMed/NCBI View Article : Google Scholar
66	Poddighe D, Comi EV, Brambilla I, Licari A, Bruni P and Marseglia GL: Increased total serum immunoglobulin e in children developing Mycoplasma pneumoniae-related extra-pulmonary diseases. Iran J Allergy Asthma Immunol. 17:490–496. 2018.PubMed/NCBI
67	Poddighe D and Marseglia GL: Is there any relationship between extra-pulmonary manifestations of Mycoplasma pneumoniae infection and atopy/respiratory allergy in children? Pediatr Rep. 8(6395)2016.PubMed/NCBI View Article : Google Scholar
68	Ye Q, Mao JH, Shu Q and Shang SQ: Mycoplasma pneumoniae induces allergy by producing P1-specific immunoglobulin E. Ann Allergy Asthma Immunol. 121:90–97. 2018.PubMed/NCBI View Article : Google Scholar
69	Liu J, He R, Wu R, Wang B, Xu H, Zhang Y, Li H and Zhao S: Mycoplasma pneumoniae pneumonia associated thrombosis at Beijing Children's hospital. BMC Infect Dis. 20(51)2020.PubMed/NCBI View Article : Google Scholar
70	Hirshberg SJ, Charles RS and Ettinger JB: Pediatric priapism associated with Mycoplasma pneumoniae. Urology. 47:745–746. 1996.PubMed/NCBI View Article : Google Scholar
71	Liu J and Li Y: Thrombosis associated with Mycoplasma pneumoniae infection (Review). Exp Ther Med. 22(967)2021.PubMed/NCBI View Article : Google Scholar
72	Pachet A, Dumestre-Perard C, Moine M, Marlu R, Rubio A and Bost-Bru C: Splenic infarction associated with transient anti-prothrombin antibodies is a rare manifestation of acute Mycoplasma pneumoniae infection. Arch Pediatr. 26:483–486. 2019.PubMed/NCBI View Article : Google Scholar
73	Dietz SM, van Stijn D, Burgner D, Levin M, Kuipers IM, Hutten BA and Kuijpers TW: Dissecting Kawasaki disease: A state-of-the-art review. Eur J Pediatr. 176:995–1009. 2017.PubMed/NCBI View Article : Google Scholar
74	Okoli K, Gupta A, Irani F and Kasmani R: Immune thrombocytopenia associated with Mycoplasma pneumoniae infection: A case report and review of literature. Blood Coagul Fibrinolysis. 20:595–598. 2009.PubMed/NCBI View Article : Google Scholar
75	Rastawicki W, Rokosz N and Jagielski M: Subclass distribution of human IgG antibodies to Mycoplasma pneumoniae in the course of mycoplasmosis. Med Dosw Mikrobiol. 61:375–379. 2009.PubMed/NCBI(In Polish).