Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 13  |  Issue : 3  |  Page : 394-402

Easy and rapid diagnosis of Mycoplasma pneumonia: is it possible?


1 Department of Chest, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Department of Pharmaceutical Microbiology, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission25-Jun-2018
Date of Acceptance06-Feb-2019
Date of Web Publication26-Jul-2019

Correspondence Address:
Reham M Elkolaly
Chest Department, Tanta University Hospitals, ElGharbyia, Tanta, 31511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejb.ejb_46_18

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  Abstract 

Background Atypical pneumonia (AP) with its different pathogens comprises a reasonable ratio of community-acquired pneumonia. Mycoplasma pneumoniae (M. pneumoniae) constitutes a known pathogen causing AP with pulmonary and extrapulmonary symptoms that necessitate early diagnosis and treatment. Serology and culture give diagnosis but after few days of infection onset.
Aim Study the incidence of M. pneumonia using PCR and relation to clinical symptoms.
Settings and design Comprehensive, prospective study.
Materials and methods A total of 80 patients with suspected AP were examined for clinical symptoms and signs such as cough, crepitations, arrhythmia and conscious level, and sputum was investigated using PCR for M. pneumoniae. Those with dry cough were subjected to fiberoptic-bronchoscopic bronchoalveolar lavage and the fluid was examined by PCR.
Statistical analysis Data were analyzed with the SPSS 22 software package.
Results Using the PCR method; M. pneumonia was 42%, mostly by bronchoscopic lavage because of dry cough, with significant correlation to arrhythmia, disturbed consciousness, and positive radiologic infiltrations (74, 65,76%, respectively).
Conclusion PCR is considered a highly specific diagnostic method for M. pneumonia. AP incidence is high in our region with special consideration to M. pneumonia as a causative agent with high percentage.

Keywords: mycoplasma, PCR, pneumonia


How to cite this article:
Elkolaly RM, Shams Eldeen MA. Easy and rapid diagnosis of Mycoplasma pneumonia: is it possible?. Egypt J Bronchol 2019;13:394-402

How to cite this URL:
Elkolaly RM, Shams Eldeen MA. Easy and rapid diagnosis of Mycoplasma pneumonia: is it possible?. Egypt J Bronchol [serial online] 2019 [cited 2019 Aug 26];13:394-402. Available from: http://www.ejbronchology.eg.net/text.asp?2019/13/3/394/263576


  Introduction Top


Atypical pneumonia (AP) comprises a reasonable ratio of pneumonia requiring hospital admission because of unusual presentation and complications [1],[2]. It is ‘atypical’ because of unusual causative organisms and atypical clinical picture [3].

It previously included rickettsia, viruses, and fungi [4], but by time it became restricted to three pathogens: Mycoplasma pneumoniae (M. pneumoniae), Chlamydophila pneumoniae, and Legionella pneumophila [3].

AP represents a rising cause of pneumonia either single [5],[6] or mixed with other bacteria [7] and the highest percentage of AP is caused by M. pneumonia [6],[8].

Patients with M. pneumonia may complain of dry cough, dyspnea, exacerbation of chronic obstructive pulmonary disease [9], and otitis media [10] in addition to nonspecific symptoms such as myalgia, heart affection [6] and leukopenia [11], all of which may aggravate disease severity.

Accurate diagnosis of M. pneumonia rarely depends on the clinical picture [12], but necessitates other diagnostic methods like culture and serological confirmation. However, they are time consuming and require complicated techniques [13] that limit their commercial use [14].

It is crucial to diagnose the causative pathogens early, rapidly, and accurately to avoid unnecessary antibiotic use and to treat and protect the patient from serious complications [15].

Real-time PCR is a recent technique that varies in reliability according to age, disease severity, and specimens’ type [16],[17]. It is a rapid technique with high sensitivity [18].


  Aim Top


The aim was to evaluate the incidence of M. pneumoniae in patients with AP using real-time PCR in addition to its relation to clinical picture.


  Patients and methods Top


In this comprehensive prospective study, 80 nonredundant clinical specimens were collected between January 2017 and January 2018, from the Chest Department, Tanta University Hospital of Egypt.

Inclusion criteria: in the form of suspicion of AP infection and clinical and radiological data in the form of low-grade fever, cough with scanty sputum, cardiac arrhythmia, increased heart rate, wheeze, crepitations, pleural rub, chest radiography patchy infiltrations with absent consolidation or pleural effusion [19],[20],[21].

Patients were excluded from the study if they were on mechanical ventilation, with lung tumor, tuberculosis, or hospital-acquired pneumonia (infection after 48 h of admission).

All patients were subjected to complete history taking, full clinical examination, general and local chest examination, routine laboratory investigation, for example, complete blood picture, erythrocyte sedimentation rate, C-reactive protein for collected samples and chest radiology [chest radiography and computed tomography (CT) when needed].

Sample collection

  1. Sputum samples: patients sit upright or at 45°, inspired deeply and hold and then coughed with expectoration into a clean container.
  2. Patients with dry cough were subjected to fiberoptic bronchoscopy (PENTAX EB-1970UK Europe GmbH Julius Vosseler Strasse 104, Hamburg, Germany) and bronchoalveolar lavage: under complete aseptic technique; bronchoscope was introduced until peripheral bronchioles, 30–50 ml of sterile saline was injected throughout. Saline was aspirated and collected in a sterile plastic container with a firmly fitted cover.


All samples were located in tubes containing PBS, vortexed and then stored at −20°C until processed [22].

Processing

Quantitative real-time PCR was done for M. pneumoniae in different respiratory samples using Microbial DNA QPCR assay kit (M. pneumoniae) (catalog no. 330033; QIAGEN Sciences, Germantown, USA). Sensitivity and specificity of real-time PCR assays in the detection of M. pneumoniae is 100%. As reported by Templeton et al. [23], the sensitivity of the real-time PCR assay reduces with the delay in collection of samples from the onset of the disease.
  1. Nucleic acid extraction from 200 µl of the specimen was done. The volume was reduced to 100 µl, and 7 µl aliquots were stored at −70°C.
  2. Purification: DNA concentration was measured at 260 nm and was greater than 10 ng/ml and the A260/A280 ratio was greater than 1.8.
  3. Preparation of master-mix: for each sample, four separate PCR reactions were prepared, including controls for positive PCR control, no template control, microbial DNA positive control, and microbial DNA QPCR assay.


The kit was utilized to calculate the load of M. pneumoniae by targeting the cytadhesin P1 gene (130bP) which is particular for M. pneumoniae.

Real-time PCR primers for P1 cytadhesin gene of M. pneumoniae:

Forward primer: CCAACCAAACAACAACGTTCA.

Reverse PRIMER: TAACGGCAACACGTAATCAGGTC.

Total volume per sample was 25 ml. The PCR mixture consisted of 12.5 ml microbial qPCR 12.5 ml, 1 ml microbial DNA qPCR assay, 5 ng genomic DNA sample, and variable amounts of microbial DNA-free water.

Plate preparation

After vortexing for 1–2 s (for mixing), the mix was put into the PCR wells. A plastic PCR plate was sealed with an adhesive optical cover and was inserted into the PCR instrument.

Performing real-time PCR

  1. Cycling condition: amplifications were done using a Light-Cycler (step 1; Applied Biosystem, Foster City, California, USA).
  2. The threshold (CT) was calculated for each well using the cycler’s software (Roche Diagnostics Ltd, Forrenstrasse, CH-6343 Rotkreuz, Switzerland).


Standard curve generation

With absolute standard curve, the copy number of the target was known. The template was accurately quantified and the sample is accurately determined to contain 1×1011 copies and diluted 10-fold eight times down to 1×103 and the PCR was performed on each dilution for three replicates.

The standard curve correlated the copy number with a particular CT. The copy number values for the unknown samples were derived by comparison to this standard curve.

Informed consent was taken from patients or relatives for the procedures and for usage of their medical data in the present study.

Tanta university ethics committee approved the study protocol.

Statistical analysis

The data were analyzed with the SPSS 22 software package (SPSS Inc., Chicago, Illinois, USA). Quantitative variables presented as mean±SD and range. Qualitative variables presented as percentages. Comparisons between groups were done with χ2 or t independent test. A P value of less than 0.05 was considered statistically significant.


  Results Top


The present study included 80 patients [32 (40%) men and 48 (60%) women] with clinical and radiological suspicion of AP ([Table 1]).
Table 1 Quantitative variables of the studied group

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Concerning the clinical data of patients with AP, most of them had pleural rub and crepitations while a small number had wheeze, arrhythmia, disturbed consciousness, and chest radiography infiltration. The incidence of M. pneumonia was 42% in all patients with AP. In all studied patients, only 36 (45%) patients had productive cough while 44 (55%) patients had dry cough, so they were subjected to bronchoscope and bronchoalveolar lavage ([Table 2]).
Table 2 Percentage in the studied group according to each of clinical characters and investigations

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According to PCR performed for M. pneumonia, there were a positive PCR group (34 patients) and negative PCR group (46 patients) with no significant difference between the two groups as regards age, sex, bronchial asthma, and steroid intake as risk factors for M. pneumonia infection ([Table 3]) and also regarding erythrocyte sedimentation rate and leukocytic count in both groups ([Table 4]).
Table 3 Distribution of demographic and clinical characters in relation to PCR results

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Table 4 Investigation results in the studied patients in relation to PCR result

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But there was statistically significant differences between the two groups as regards pleural rub, chest wheeze, crepitations, state of consciousness, heart rate, and arrhythmia ([Table 3]). In addition, there was a significant difference between the type of examined sample for M. pneumonia ([Table 4]).

The PCR positive group and the PCR negative group were significantly different as regards chest radiography infiltration and C-reactive protein results ([Table 4]).

The higher percentage of disturbed consciousness, chest radiography infiltrations, arrhythmia, and wheeze in patients with AP were mainly found in those with M. pneumoniae; in addition most of the patients subjected to BAL sampling were those with M. pneumonia ([Table 5]).
Table 5 Clinical data of Mycoplasma pneumoniae positive group regarding the studied patients

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Positive and negative result curves show amplification and no amplification, respectively ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
Figure 1 Positive PCR control curve (human DNA to assure the extraction and amplification process).

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Figure 2 Positive Mycoplasma pneumoniae control curve.

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Figure 3 Positive result curve shows amplification.

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Figure 4 Negative result curve shows no amplification.

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  Discussion Top


AP constitutes a considerable percentage of community-acquired pneumonia in both adults and children [6]. M. pneumonia represents 20–40% of community-acquired pneumonia [24].

The present study included 80 patients with suspected AP without previous identification of the causative agents. Patients with productive cough were subjected to sputum examination by PCR for M. pneumonia, and those with dry cough were examined bronchoscopically for BAL that was examined also for M. pneumonia using PCR.

The patients were classified retrospectively to positive and negative groups regarding the result of PCR for M. pneumonia, and each group was correlated to recorded clinical parameters of the patients.

In the present study, the mean of patients’ age with AP was 46.41 (60%) years and most of them were women. However, the mean age in M. pneumonia positive group was 44.44 (18%) years and most of them were men.

These findings were concomitant with that of Shangguan et al. [15], who reported a higher percentage of M. pneumoniae in men than women. And also in a study by Dash et al. [20] for 130 patients with AP, women were 35 (27%) while men were 95(73%).

In the present study, BAL constituted 79.5% while sputum was 20.9% of the examined samples in M. pneumoniae positive group. The PCR results may differ according the type of sample used; for example, sputum, lavage, or swab [22].

Previous studies have stated that the PCR used for sputum is superior to that for nasopharyngeal swabs followed by throat swabs that give least results using PCR. Raty et al. [25] described 69% sensitivity for sputum samples and 50% and 37.5% for throat swabs and nasopharyngeal swabs, respectively, but no distinctive differences were stated by Stralin et al. [26] between sputum samples and throat swabs.

In the present study; the used real-time PCR technique had diagnosed M. pneumoniae in 34% of cases with AP that constituted a high diagnostic value with high sensitivity and specificity of this new method.

This agrees with the results published by Zhao et al. [27] who investigated 60 M. pneumoniae clinical specimens in one of the China hospitals by using MpP1 real-time PCR. Also, in a study by Chaudhry et al. [28] when compared serology with sputum secretions for M. pneumonia diagnosis, the PCR result was 19.4% while serology detected only 6.7% of cases.

Moreover, Sondergaard et al. [29] searched 746 patients with respiratory tract infection using the PCR test and found 134 of patients had positive results for M. pneumoniae.

Nilsson et al. [30] studied 164 patients during a community outbreak of M. pneumonia infection and compared patients’ serology with PCR results of oropharyngeal swabs and stated the high diagnostic value of PCR especially in the early stage of the disease in comparison to serology results.

In our PCR-positive group for M. pneumoniae, wheeze was auscultated in 44% of cases, crepitations in 56%, and arrhythmia in 74% of cases; 79.5% of patients had dry cough and just 20.5% of patients had productive cough.

In partial similarity, Shangguan et al. [15] stated dry and productive cough in 54.5% and 26.1% out of 88 patients, respectively, and 25% of the studied patients had crepitations.While Rahimian and Hosseini [31] stated after his study (for the Hajj pilgrims) that absence of cough made the diagnosis of M. pneumoniae unlikely. Dash et al. [20] stated a significant presence of cough (90%), dyspnea (63%), chest pain (57%), and sore throat (27%) in M. pneumonia positive group when they studied different diagnostic methods for M. pneumonia detection.

Chen et al. [32] recorded 24.4% of cases had wheeze and 6.5% had dyspnea and positive radiological finding in 36% cases.

All of that proved the importance of clinical presentation especially cough and extrapulmonary symptoms in early suspicion of M. pneumoniae.

In the present study, the incidence of M. pneumonia (in those with suspected AP) was 42%; this ratio is not a low percentage and was related or even higher than those obtained by other physicians in their related studies.

However, Sondergaard et al. [29] in their study recorded that 17.96% of cases had M. pneumoniae as a cause of AP. Nilsson et al. [30] recorded a ratio of 11.02% out of 8157 studied patients.

Moreover, Chen et al. [32] stated the incidence of M. pneumonia as 14.58% in 2009 and 13.99% in 2010 when they studied its incidence in respiratory secretions of admitted patients with suspected AP for 3 consecutive years.

In their study, Chaudhry et al. [28] concluded 19% incidence of M. pneumonia in 134 patients with pneumonia. In addition, Touati et al. [33] studied 540 patients with lower respiratory tract infection and found that 23.3% of cases had M. pneumoniae as a cause of pneumonia.

This implies the high percentage of M. pneumoniae in patients with lower respiratory tract infections in relation to other causative agents causing AP.

This relatively high ratio in the present study may be related to the socioeconomic status of our developing country and the need for more improvement in hygienic measures to avoid or even lessen these infections.

More studies are suggested to survey the incidence of pneumonia including all suspected causative agents as an important step in the national controlling programs concerning human health in developing countries that suffer poverty of the recording system for patients’ data.

One of the limitations of this study is its neglect of other diagnostic tools for M. pneumonia such as culture or serological methods to correlate with the methods used in the study.

Another limitation is not declaring the percentage of other isolated organisms causing pneumonia other than M. pneumonia.


  Conclusion Top


M. pneumoniae incidence is not low among patients with AP.

Chest radiology and clinical presentation are undoubtedly important in early suspicion and detection of M. pneumoniae, but with no comparable diagnostic accuracy to serology and culture. But serology does not give the required high sensitivity in the early days of the infection period. Moreover, culture needs specific precautions and long time to give the required colonies, that delay early specific and effective treatment.

PCR is a considerable specific method for the diagnosis of M. pneumoniae especially when time factor is an essential matter in early and successful treatment strategies. It gives specific and accurate results with the required quantitative calculation of bacterial infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Alvarez-Lerma F, Torres A. Severe community-acquired pneumonia. Curr Opin Crit Care 2004; 10:369–374.  Back to cited text no. 1
    
2.
Arnold FW, Summersgill JT, Lajoie AS, Peyrani P, Marrie TJ, Rossi P et al. A worldwide perspective of atypical pathogens in community-acquired pneumonia. Am J Respir Crit Care Med 2007; 175:1086–1093.  Back to cited text no. 2
    
3.
Yu Y, Fei A. Atypical pathogen infection in community-acquired pneumonia. Biosci Trends 2016; 10:7–13.  Back to cited text no. 3
    
4.
Murdoch DR, Chambers ST. Atypical pneumonia − time to breathe new life into a useful term? Lancet Infect Dis 2009; 9:512–519.  Back to cited text no. 4
    
5.
Capelastegui A, Espana PP, Bilbao A, Gamazo J, Medel F, Salgado J et al. Etiology of community-acquired pneumonia in a population-based study: link between etiology and patients characteristics, process-of-care, clinical evolution and outcomes. BMC Infect Dis 2012; 12: 134.  Back to cited text no. 5
    
6.
Morozumi M, Takahashi T, Ubukata K. Macrolide-resistant Mycoplasma pneumoniae: characteristics of isolates and clinical aspects of community-acquired pneumonia. J Infect Chemother 2010; 16:78–86.  Back to cited text no. 6
    
7.
Chaudhry R, Ghosh A, Chandolia A. Pathogenesis of Mycoplasma pneumoniae: an update. Indian J Med Microbiol 2016; 34:7–16.  Back to cited text no. 7
    
8.
Chen K, Jia R, Li L, Yang C, Shi Y. The aetiology of community associated pneumonia in children in Nanjing, China and aetiological patterns associated with age and season. BMC Public Health 2015; 15:113.  Back to cited text no. 8
    
9.
Housset B. Rising to the challenge of resistance: a case study-based discussion. Int J Antimicrob Agents 2007; 29(Suppl 1):S11–S16.  Back to cited text no. 9
    
10.
Walter ND, Grant GB, Bandy U, Alexander NE, Winchell JM, Jordan HT et al. Community outbreak of Mycoplasma pneumoniae infection: school-based cluster of neurologic disease associated with household transmission of respiratory illness. J Infect Dis 2008; 198:1365–1374.  Back to cited text no. 10
    
11.
Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med 2014; 371: 1619–1628.  Back to cited text no. 11
    
12.
Plouffe JF. Importance of atypical pathogens of community-acquired pneumonia. Clin Infect Dis 2000; 31(Suppl 2):S35–S39.  Back to cited text no. 12
    
13.
Loens K, Goossens H, Ieven M. Acute respiratory infection due to Mycoplasma pneumoniae: current status of diagnostic methods. Eur J Clin Microbiol Infect Dis 2010; 29:1055–1069.  Back to cited text no. 13
    
14.
Burillo A, Bouza E. Chlamydophila pneumoniae. Infect Dis Clin North Am 2010; 24:61–71.  Back to cited text no. 14
    
15.
Shangguan Z, Sun Q, Zhang M, Ding J, Yi L, Gao Y et al. Mycoplasma pneumoniae infection in hospitalized adult patients with community-acquired pneumonia in China. J Infect Dev Ctries 2014; 8:1259–1266.  Back to cited text no. 15
    
16.
Thurman KA, Walter ND, Schwartz SB, Mitchell SL, Dillon MT, Baughman AL et al. Comparison of laboratory diagnostic procedures for detection of Mycoplasma pneumoniae in community outbreaks. Clin Infect Dis 2009; 48:1244–1249.  Back to cited text no. 16
    
17.
Agamy GRWS, Ahmed AO, Bakar LM. Real-time polymerase chain reaction as an alternative method for diagnosis of multidrug-resistant tuberculosis: can it stand alone in this concern? Egypt J Bronchol 2017; 11:342–345.  Back to cited text no. 17
    
18.
Thurman KA, Warner AK, Cowart KC, Benitez AJ, Winchell JM. Detection of Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella spp. in clinical specimens using a single-tube multiplex real-time PCR assay. Diagn Microbiol Infect Dis 2011; 70:1–9.  Back to cited text no. 18
    
19.
Sharma L, Losier A, Tolbert T, Dela Cruz CS, Marion CR. Atypical pneumonia: updates on Legionella, Chlamydophila, and Mycoplasma Pneumonia. Clin Chest Med 2017; 38:45–58.  Back to cited text no. 19
    
20.
Dash S, Chaudhry R, Dhawan B, Dey AB, Kabra SK, Das BK. Clinical spectrum and diagnostic yields of Mycoplasma pneumoniae as a causative agent of community-acquired pneumonia. J Lab Physicians 2018; 10:44–49.  Back to cited text no. 20
    
21.
Bjorn AM, Lebech AM. Extrapulmonary complications of Mycoplasma pneumoniae infections. Ugeskr Laeger 2002; 164:1805–1809.  Back to cited text no. 21
    
22.
Kim JS, Hackley GH, Okamoto K, Rubin BK. Sputum processing for evaluation of inflammatory mediators. Pediatr Pulmonol 2001; 32:152–158.  Back to cited text no. 22
    
23.
Templeton KE, Scheltinga SA, Graffelman AW, Van Schie JM, Crielaard JW, Sillekens P et al. Comparison and evaluation of real-time PCR, real-time nucleic acid sequence-based amplification, conventional PCR, and serology for diagnosis of Mycoplasma pneumoniae. J Clin Microbiol 2003; 41:4366–4371.  Back to cited text no. 23
    
24.
Chaudhry R, Valavane A, Sreenath K, Choudhary M, Sagar T, Shende T et al. Detection of Mycoplasma pneumoniae and Legionella pneumophila in patients having community-acquired pneumonia: a multicentric study from New Delhi, India. Am J Trop Med Hyg 2017; 97:1710–1716.  Back to cited text no. 24
    
25.
Raty R, Ronkko E, Kleemola M. Sample type is crucial to the diagnosis of Mycoplasma pneumoniae pneumonia by PCR. J Med Microbiol 2005; 54(Pt 3):287–291.  Back to cited text no. 25
    
26.
Stralin K, Tornqvist E, Kaltoft MS, Olcen P, Holmberg H. Etiologic diagnosis of adult bacterial pneumonia by culture and PCR applied to respiratory tract samples. J Clin Microbiol 2006; 44:643–645.  Back to cited text no. 26
    
27.
Zhao F, Cao B, He LH, Yin YD, Tao XX, Song SF et al. Evaluation of a new real-time PCR assay for detection of Mycoplasma pneumoniae in clinical specimens. Biomed Environ Sci 2012; 25:77–81.  Back to cited text no. 27
    
28.
Chaudhry R, Sharma S, Javed S, Passi K, Dey AB, Malhotra P. Molecular detection of Mycoplasma pneumoniae by quantitative real-time PCR in patients with community acquired pneumonia. Indian J Med Res 2013; 138:244–251.  Back to cited text no. 28
    
29.
Sondergaard MJ, Friis MB, Hansen DS, Jorgensen IM. Clinical manifestations in infants and children with Mycoplasma pneumoniae infection. PLoS One 2018; 13:e0195288.  Back to cited text no. 29
    
30.
Nilsson AC, Bjorkman P, Persson K. Polymerase chain reaction is superior to serology for the diagnosis of acute Mycoplasma pneumoniae infection and reveals a high rate of persistent infection. BMC Microbiol 2008; 8:93.  Back to cited text no. 30
    
31.
Rahimian M, Hosseini BM. Serological study of Bordetella pertussis, Mycoplasma pneumonia and Chlamydia pneumonia in Iranian hajj pilgrims with prolonged cough illnesses: a follow-up study. Respir Med 2017; 132:122–131.  Back to cited text no. 31
    
32.
Chen ZR, Yan YD, Wang YQ, Zhu H, Shao XJ, Xu J et al. Epidemiology of community-acquired Mycoplasma pneumoniae respiratory tract infections among hospitalized Chinese children, including relationships with meteorological factors. Hippokratia 2013; 17:20–26.  Back to cited text no. 32
    
33.
Touati A, Pereyre S, Bouziri A, Achour W, Khaldi A, Ben Jaballah N et al. Prevalence of Mycoplasma pneumoniae-associated respiratory tract infections in hospitalized children: results of a 4-year prospective study in Tunis. Diagn Microbiol Infect Dis 2010; 68:103–109.  Back to cited text no. 33
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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