(570) Hidden in Plain Sight: A Case of Extragenital Mycoplasma Infection

Introduction: Mycoplasma species (M. spp) are unidentifiable by Gram stain and resistant to agents targeting cell wall synthesis. With uncommon extragenital infections, diagnosis and treatment can be delayed. We detail a case of shock from multiple M. spp.

Description: A 50-year-old woman with hypothyroidism and immune thrombocytopenia treated with rituximab over a year ago underwent scheduled total laparoscopic hysterectomy and bilateral salpingectomy without complication. Days later she was readmitted with abdominal pain and fevers. Imaging showed periumbilical and lower abdominal wall rim-enhancing fluid collections concerning for abscesses. The patient underwent vaginal drain placement with cuff revision and pelvic washout. Fluid culture grew Enterococcus spp., and she was discharged on a beta-lactam. Unfortunately, her pain and fevers returned requiring readmission. She had recurrent vaginal cuff dehiscence and needed intraabdominal drain placement with repeat washouts at the abdominal incision sites. Each Gram stain showed polymorphonuclear leukocytes sans microbes, and cultures were negative. Vancomycin, beta-lactams, a sulfonamide, and antifungals were trialed without significant response. A partial omentectomy was performed for indurated omenta. ICU admission was warranted for septic shock requiring vasopressors and intubation. The hospital course was complicated by influenza A. Blood cultures, MRSA screening, gonorrhea/chlamydia/trichomonas, HIV, and syphilis testing were negative. Labs revealed hypogammaglobulinemia, so IVIG was given. Given her lack of clinical improvement, doxycycline/moxifloxacin was started. Direct 16S rRNA sequencing of an intraabdominal fluid sample made the diagnosis of extragenital M. hominis and Ureaplasma urealyticum coinfection. Directed antimicrobial therapy was continued, and this patient recovered.

Discussion: We suspect postsurgical complications led to abdominal contamination with vaginal flora. Despite robust antibiotics and presumed source control, the patient still suffered from recurrent dehiscence from M. spp. With complicated intraabdominal infections where there is recent urogenital surgery, ongoing fevers, and immunosuppression, we need a high index of suspicion for M. spp when a Gram stain is negative and broad-spectrum antibiotics prove futile.