Description
Diagnosing mycoplasma infection in the UK Mycoplasma infection in the immunocompetent is fortunately rarely life-threatening. Most clinicians are familiar with Mycoplasma pneumoniae, a common cause of pneumonitis in young adults that is usually self-limiting, and in more severe cases usually responds to macrolides. Neonatologists are familiar with potentially lethal systemic infection in babies with a variety of mycoplasma species acquired from the urogenital tract during birth, usually affecting premature infants who are probably partially immunocompromised. Genito-urinary specialists are aware that mycoplasmas can cause urethritis and may contribute to vaginitis, but the extent of the problem is not clear and there is usually no attempt to systematically test for infection.
The situation in primary antibody deficiency (PAD) is quite different, with about 5% of patients developing severe infection with high morbidity and some mortality. In this Bulletin, Matthew Buckland and colleagues describe a typical scenario where the diagnosis was delayed for a variety of reasons. Despite numerous case reports and reviews in the medical literature, few physicians and surgeons are aware that PAD patients are prone to mycoplasma infection; therefore immunologists must monitor these patients regularly and should not be embarrassed about being actively involved in identifying the causative organism for suspected infection, even if the patient has been referred for another specialist opinion.
Unfortunately, the process for diagnosing mycoplasma infection is not straightforward because few laboratories in the UK have appropriate facilities, and the PHLS has no formal dedicated laboratory in this area. However, many large hospitals now have access to PCR kits that can recognise some mycoplasma species, particularly M. pneumoniae and ureaplasmas. Although this can be helpful in the initial stages of diagnosis, it does not provide information on antibiotic sensitivity. As seen in Dr Buckland’s case, many PAD patients with chronic infection have organisms that are resistant to standard antibiotics, and it is important to know this as soon as possible. There are currently only two laboratories in the UK able to offer a service for mycoplasma culture; one is a commercial veterinary laboratory focussed on diagnosing infection in animals (Mycoplasma Experience, Reigate. Surrey), and the other is in the Medical Microbiology laboratory at the Royal Free Hospital in Hampstead, London. These laboratories, with a few scientists at PHLS with an interest in mycoplasmas, are in regular touch with each other and there is an agenda to create a formal National facility within the next few years. Such a centre will need to have constant access to microbiologists and immunologists experienced in using novel antibiotics, such as Econor, for resistant infections.
In conclusion, immunologists should be aware of the problems outlined above, and should not assume that a specimen sent to their local laboratory to test for mycoplasmas will generate useful clinical advice within a reasonable time.
It will not come as a surprise to our readers that the forces of change are at work in the organisation of the NHS. With the advent of specialised commissioning, there will be tremendous change in the way in which our laboratories and clinics are funded. Those of us practising Immunology and Allergy will have to come to terms with three new definitions of specialised services. In the last issue, we presented the new definition of Specialised Immunodeficiency Services. In this issue of CPD Bulletin in Immunology & Allergy we have reproduced the definition of Specialised Allergy Services, and in a future edition we will
distribute the definition of Specialised Immunology Laboratory Services, once the definitive version has been published by the Department of Health.
All three documents represent a great deal of discussion and debate, and will no doubt generate much more. Many practitioners will wonder how they managed to provide a service at all once they see some of the elements of practice outlined in these documents. Policies of perfection are all very well when infinite time and resources are available with which to implement them. But the real world is not like that. Many of the specialised services outlined in these definitions have been, and continue to be provided by well-trained and appropriately skilled practitioners around the country, although often in centres which are severely under-resourced. In these days of severe difficulties in recruiting to Immunology and Allergy, it is vital that Immunologists and Allergists do not feel disenfranchised by these proposals. Specialists have special skills – and continue to develop these long after their official training period is over; failing to recognise this, and enforcing limitations on practice by starvation of resources will be counter-productive.
As seen in the Government’s plans for Pathology Modernisation, there are ways in which we can make positive progress. The emerging concept of ‘Managed Networks’ is a real attempt to solve some of the difficulties facing single-handed practitioners in Immunology and Allergy. Combining elements of decentralisation, joint decision-making and risk sharing, the Managed Network may be a way forward for the development of comprehensive Immunology and Allergy Services without making existing specialists feel decidedly unspecial.
Dr David Webster
Editor
