Joo Hee Chang, et al. the development of hepatotoxicity. Azithromycin- induced hepatotoxicity has been reported infre- quently only in adults. The usual development and time course of the liver injury, from the beginning of azithromycin therapy to the onset of symptoms, has been reported to be 5 to 10 days.17,18 In our patient, azithromycin was administered from the 1st to 3rd hospital day and the aggravation of acute hepatitis occurred on the 4th hospital day. Although the possibility remains that azithromycin was the cause of hepatitis in our patient, this is less likely, since the liver enzymes were elevated acutely right after the initiation of azithromycin therapy. Our patient showed depressed levels of multiple coagulation factors as well as acute hepatitis. In several reports, M. pneumoniae infection can be associated with transient acquired factor II, VIII, or X deficiencies with clinical manifestations of bleeding tendency.19-21 In our case, coagulation tests revealed prolonged aPTT and decreased coagulation factors activity, including factors VIII, IX, XI, and XII, without any bleeding tendency. The coagulation tests were monitored regularly, and showed progressive normalization without specific treatment. Both the absence of a bleeding tendency in earlier life and the normalization of prolonged PTT and coagulation factor activity suggested that congenital factors deficiency was not the cause of abnormalities. There was no prior report in the English medical literature on the depression of multiple coagula- tion factors associated with mycoplasma infection. The pathogenesis of this phenomenon in our patient is unknown. One possible mechanism is a consumptive coagulopathy due to hepatic deterio- ration. The other mechanism is the presence of circulating inhibitors. It is well established that mycoplasma infection can cause hemolysis due to the development of autoantibodies including cold agglutinins.22 The presence of circulating inhibitors specific to coagulation factors is supported by the PTT mixed with normal plasma that failed to correct prolonged PTT. In conclusion, we report the first case of M. pneumoniae infection in a child presenting with acute hepatitis and transient depression of multiple coagulation factors. Yonsei Med J Vol. 49, No. 6, 2008 REFERENCES 1. Waites KB. New concepts of Mycoplasma pneumoniae infections in children. Pediatr Pulmonol 2003;36:267-78. 2. Eun BW, Kim NH, Choi EH, Lee HJ. Mycoplasma pneumoniae in Korean children: the epidemiology of pneumonia over 18-year period. J Infect 2008;56:326-31. 3. Kim JH, Chae SA, Lee DK. Clinical findings of Mycoplasma pneumonia in children, from 1998 to 2003. Korean J Pediatr 2005;48:969-75. 4. Lee JK, Hong CH, Sohn YM, Kim KE, Kim DH, Kim PK, et al. Mycoplasmal pneumonia in children. Yonsei Med J 1986;27:300-6. 5. Cherry JD, Ching N. Mycoplasma pneumoniae. In: Feigin RD, Cherry JD, editors. Textbook of Pediatric Infectious Diseases. 5th ed. Philadelphia: W.B. Saunders; 2004. p.2516-31. 6. Horii Y, Sugimoto T, Sakamoto I, Sawada T. Acute acalculous cholecystitis complicating Mycoplasma pneumoniae infection. Clin Pediatr (Phila) 1992;31:376-8. 7. Lee YS, Hong CH, Lee C, Lee SG. Unusual forms of pulmonary and extrapulmonary manifestations of mycoplasmal pneumonia. Korean J Pediatr 1989;32: 1064-73. 8. Suzuyama Y, Iwasaki H, Izumikawa K, Hara K. Clinical complications of Mycoplasma pneumoniae disease: other organs. Yale J Biol Med 1983;56:487-91. 9. Arav-Boger R, Assia A, Spirer Z, Bujanover Y, Reif S. Cholestatic hepatitis as a main manifestation of Mycoplasma pneumoniae infection. J Pediatr Gastro- enterol Nutr 1995;21:459-60. 10. Grüllich C, Baumert TF, Blum HE. Acute Mycoplasma pneumoniae infection presenting as cholestatic hepatitis. J Clin Microbiol 2003;41:514-5. 11. Lee JT, Kim HS, Tchah H. Hepatitis complicated with Mycoplasma pneumoniae infection. Korean J Pediatr Gastroenterol Nutr 2001;4:207-12. 12. Kountouras D, Deutsch M, Emmanuel T, Georgiadis G, Koskinas J. Fulminant Mycoplasma pneumoniae infection with multi-organ involvement: a case report. Eur J Intern Med 2003;14:329-31. 13. Fernald GW. Immunologic mechanisms suggested in the association of M. pneumoniae infection and extra- pulmonary disease: a review. Yale J Biol Med 1983;56: 475-9. 14. Jansson E, Wegelius R, Visakorpi JK. Chronic active hepatitis and concomitant mycoplasma infection. Lancet 1972;1:1395. 15. Principi N, Esposito S. Comparative tolerability of erythromycin and newer macrolide antibacterials in paediatric patients. Drug Saf 1999;20:25-41. 16. Fox JC, Szyjkowski RS, Sanderson SO, Levine RA. Progressive cholestatic liver disease associated with clarithromycin treatment. J Clin Pharmacol 2002;42:676- 80. 17. Chandrupatla S, Demetris AJ, Rabinovitz M. Azithro- mycin-induced intrahepatic cholestasis. Dig Dis Sci 2002;