Acute Hepatitis with Mycoplasma pneumoniae Infection and Transient Depression of Multiple Coagulation Factors A B Fig. 3. The portal area (A) and hepatic lobule (B) show features of acute hepatitis such as ballooning degeneration, spotty necrosis and increased Kupffer cell activity (H & E, × 400). The patient is currently being followed up as an outpatient. DISCUSSION M. pneumoniae infection can be associated with dermatologic, cardiologic, neurologic, hematologic, and musculoskeletal manifestations.1,5 Gastrointes- tinal manifestations including hepatitis, acute acalculous cholecystitis,6 and pancreatitis have been reported.5 Elevated liver enzymes are fre- quently observed during M. pneumoniae infection in children. Lee et al.7 and Suzuyama et al.8 reported that 15.2% and 36.2% of patients pre- senting with serologically confirmed M. pneumoniae infection, respectively, had an evidence of liver involvement. Liver involvement was transitory in these patients, and recovery of liver enzymes to normal range correlated directly with resolution of mycoplasma pneumonia, as demonstrated in our patient. Most previous case reports showed that liver involvement of M. pneumoniae infection is chole- stasis rather than hepatic necrosis.9,10 Hypoalbu- minemia, hyperbilirubinemia, and hepatomegaly are characteristics as signs of hepatobiliary invol- vement in mycoplasma infections.11 The rapid progression of hepatomegaly with exacerbation of hepatitis was observed in this case. Moreover, hypoalbuminemia and depressed levels of mul- tiple coagulation factors produced by the liver were also observed, but hyperbilirubinemia was not present in this case. Hyperbilirubinemia usually occurs as the indirect type because of hemolysis in mycoplasma infection. While cholestasis is very rare, some cases of cholestatic hepatitis have been reported in children.9 Hepatitis has been reported in a case with M. pneumoniae-associated multiple organ involvement.12 The pathogenesis of M. pneumoniae-associated hepatitis is unknown. Never- theless, possible mechanisms include direct inva- sion of the organisms and autoimmunity including the production of autoantibodies, such as cold agglutinins.13 Liver biopsies have been performed in rare cases of M. pneumoniae-associated hepatitis, and showed massive hepatocellular destruction and inflamma- tory infiltration in one patient,14 while non-specific, mild lobular hepatitis has also been reported.12 Liver biopsies performed on 3 patients showed hepatic dysfunction with histological findings consistent with a non-specific reactive hepatitis in each case.8 In our case, the liver biopsy showed severe and acute lobular hepatitis. It is important to consider that liver toxicity has been observed with almost every class of medica- tion. The association of macrolide antibiotics with cholestatic hepatitis is well known.15,16 Although erythromycin, clarithromycin, and other macrolides were correlated with cholestatic liver injury, azithromycin was not associated commonly with Yonsei Med J Vol. 49, No. 6, 2008