Case report Acute hepatitis due to Mycoplasma pneumoniae infection without lung involvement in adult patients Manuel Romero-Go ´mez 1, * ,M a Angeles Otero 1 , Diego Sa ´nchez-Mun ˜oz 1 , Mercedes Ramı ´rez- Arcos 2 , Jose ´ L. Larraona 1 , Emilio Sua ´rez Garcı ´a 1 , Julio Vargas-Romero 2 1 Digestive Diseases Unit, Hospital Universitario de Valme, Ctra Ca ´diz s/n 41014, Sevilla, Spain 2 Microbiology Unit, Hospital Universitario de Valme, Sevilla, Spain Mycoplasma pneumoniae has been associated with cholestatic hepatitis in children, while in adults, the lack of liver involvement has been considered as a typical feature of M. pneumoniae infection. Controversial data have been reported about the possibility of liver involvement with M. pneumoniae community-acquired pneumonia. We present two cases of acute hepatitis associated with M. pneumoniae infection without lung involvement. q 2006 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. Keywords: Acute hepatitis; Mycoplasma pneumoniae 1. Introduction Viral hepatitis has been considered the main cause of acute hepatitis in western countries. Among non-viral causes of chronic hepatitis, Wilson’s disease or autoimmune hepatitis must be ruled out. When acute hepatitis syndrome associates with fever, Herpes simplex, Cytomegalovirus and Epstein-Barr virus infections need to be excluded. Some bacterial infections should also be considered, such as Brucella [1], Salmonella [2], or Rickettsia [3]. Mycoplasma pneumoniae has been associated with cholestatic hepatitis in children [4], whereas in adults M. pneumoniae infection usually occurs without liver involvement. Recently, a hot discussion came up about the possibility of liver disease associated with M. pneumoniae community-acquired pneu- monia [5,6]. We present two patients suffering from M. pneumoniae infection without pneumonia with liver involvement. Case no 1. A 22-year-old male reporting alcohol consumption of around 60 g per day and smoking 20 cigarettes per day, without known allergies was attended as inpatient owing to 2 weeks suffering from fever higher than 38 8C and back pain. Ciprofloxacin and tobramycin were prescribed based on the suspicion of pyelonephritis. Liver function tests showed aspartate aminotransferase (AST) 217 U/L (5-37), alanine–aminotransferase (ALT) 355 U/L (5– 41), g-glutamil–transpeptidase (GGT) 170 U/L (!66), alkaline Phosphatase (AP) 150 U/L (!129). Total serum bilirubin 1.56 mg/dl. Red and white blood cells and platelets counts were normal. Chest X-ray was normal. HBsAg, anti- HCV-IgG, anti-HEV-IgM, anti-HAV-IgM, anti-EBV-IgM, anti-CMV-IgM were negatives. IgM antibodies against Brucella, Salmonella, Rickettsia and Coxiella were also negative. Anti-HBc-IgG was positive, but HCV RNA and HBV DNA were undetectable. Antibodies against Legio- nella and Leptospira by indirect immuno-fluorescence were also negative. Lastly, anti-M. pneumoniae-IgM was positive (O1/160) and IgG negative. Antinuclear antibodies were negative. Liver ultrasonography did not detect abnormal- ities. Levofloxacin (500 mg/24 h) was administered for 7 days, with disappearance of fever and pain. One month later, transaminase levels decreased, anti-IgG M. pneumoniae turned positive and anti-IgM remained positive. Two months later anti-IgM disappeared, liver function tests were found normal and anti-IgG M. pneumoniae remained positive. Case no 2. A 22-year-old female came to our Unit because of fever and asthenia since 3 days before. She was under treatment with ibuprofen and metronidazole because of a dental abscess. A routine biochemical analysis showed AST and ALT values of 256 U/L (5–37) and 402 U/L Journal of Hepatology 44 (2006) 827–828 www.elsevier.com/locate/jhep 0168-8278/$32.00 q 2006 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.jhep.2005.12.014 Received 3 December 2005; received in revised form 14 December 2005; accepted 19 December 2005; available online 24 January 2006 * Corresponding author. Tel.: C349 5501 5759; fax: C349 5501 5885. E-mail address: mromerog@supercable.es (M. Romero-Go ´mez).