Development of a nomogram for predicting refractory Mycoplasma pneumoniae pneumonia in children: a prospective study
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Key findings
• This study identified prolonged fever duration, increased duration of glucocorticoid use, and elevated serum YKL-40 as independent risk factors for refractory Mycoplasma pneumoniae pneumonia (RMPP) in children. A predictive nomogram model built on these factors demonstrated excellent discriminative performance (area under the curve =0.92), offering a practical tool for early identification and risk stratification of RMPP.
What is known and what is new?
• It is known that RMPP is a serious subtype of Mycoplasma pneumoniae pneumonia associated with poor treatment response and complications, but early prediction remains clinically challenging. Previous studies have suggested roles for biomarkers such as C-reactive protein, lactate dehydrogenase, and D-dimer; however, their accuracy is limited and largely debated.
• This study is the first to comprehensively evaluate YKL-40 and interleukin-37 (IL-37) as prognostic biomarkers in RMPP, revealing that elevated YKL-40 and longer fever and glucocorticoid therapy independently predict RMPP. Notably, the study also reports decreased IL-37 expression in RMPP, indicating a possible protective role.
What is the implication, and what should change now?
• The established nomogram enables clinicians to quantitatively estimate RMPP risk using three accessible parameters: fever duration, glucocorticoid use, and serum YKL-40. This facilitates early identification, risk stratification, and optimized management of children at high risk for RMPP in clinical practice. Incorporation of YKL-40 as a biomarker may improve current diagnostic protocols. Further multicenter validations are needed before widespread adoption.
Introduction
Mycoplasma pneumoniae (MP) is a common pathogen responsible for community-acquired pneumonia (CAP) in children, accounting for 10% to 40% of cases (1). Although most infections are self-limiting, a significant proportion of children develop refractory Mycoplasma pneumoniae pneumonia (RMPP), which is characterized by persistent fever and progressive pulmonary infiltrates despite adequate macrolide therapy (2). RMPP may lead to serious complications, including necrotizing pneumonia, plastic bronchitis, and long-term pulmonary sequelae, making its early identification and management a critical clinical challenge (2,3).
The pathogenesis of RMPP is complex and is believed to involve a dysregulated host immune response rather than direct damage from the pathogen itself. While conventional inflammatory markers such as white blood cell (WBC), C-reactive protein (CRP), lactate dehydrogenase (LDH), and D-dimer are often elevated, they lack the specificity required for accurate early prediction (4-8). Consequently, recent research has focused on identifying more specific mediators involved in the immunopathology of RMPP. For instance, a study has investigated the role of specific pro-inflammatory cytokines, with meta-analyses demonstrating a significant association between elevated interleukin-17 (IL-17) levels and severe MPP (9). Interleukin-6 (IL-6) and interleukin-10 (IL-10) have been implicated as a predictive indicator for RMPP in previous studies conducted by our research group (10). A recent study identified IL-6 and erythrocyte sedimentation rate (ESR) as risk factors for RMPP in children (11).
Although studies on cytokines have provided valuable insights into the immune mechanisms of RMPP, the multifactorial complexity of the disease suggests that relying solely on currently known inflammatory markers may be insufficient for building a highly accurate predictive model (4-8). The processes of inflammatory response and tissue remodeling constitute a far more intricate network. Therefore, turning our attention to novel biomarkers that have demonstrated significant roles in other respiratory diseases but remain underexplored in RMPP could offer a unique perspective. For instance, chitinase 3-like 1 (YKL-40), a glycoprotein involved in inflammation and tissue remodeling, has emerged as a promising biomarker in other respiratory diseases like asthma and chronic obstructive pulmonary disease (12). In parallel, interleukin-37 (IL-37), an important anti-inflammatory cytokine, plays a crucial counter-regulatory role in various inflammatory and autoimmune disorders and exhibits broad anti-pathogenic properties (13,14). Given their established relevance in other inflammatory diseases, investigating the potential roles of YKL-40 and IL-37 in the pathogenesis of RMPP is both necessary and promising
Accordingly, this study was designed to determine the predictive utility of serum YKL-40 and IL-37 for RMPP in children. Our primary objectives were to ascertain their status as independent risk factors and subsequently to construct and validate a novel nomogram. By integrating these biomarkers with other established clinical parameters, we aimed to create a robust predictive tool to facilitate early risk stratification and guide therapeutic decision-making. We present this article in accordance with the TRIPOD reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-407/rc).
Methods
Study design and participants
This prospective study enrolled children with MPP who visited The Second People’s Hospital of Changzhou (the Third Affiliated Hospital of Nanjing Medical University) between June and December 2024. Inclusion criteria: (I) aged 1–14 years; (II) hospitalized for ≥1 week; (III) positive MP polymerase chain reaction (PCR) test from throat swab. Exclusion criteria: (I) mixed infections; (II) history of major surgery and trauma within the last 3 months; (III) severe hepatic or renal insufficiency; (IV) cardiovascular diseases; (V) neurological diseases; (VI) autoimmune diseases; (VII) hematologic diseases; (VIII) chronic lung diseases such as bronchodilatation, asthma; (IX) long-term use of immunosuppressive medications; (X) use of hormones within 2 weeks prior to enrollment; (XI) incomplete or missing medical records.
RMPP group: persistent fever and progressive pulmonary infiltrates despite ≥7 days of standard macrolide therapy (2).
Non-RMPP (NRMPP) group: clinical improvement within 7 days of standard macrolide therapy and did not develop the refractory features above during the disease course.
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The Second People’s Hospital of Changzhou, the Third Affiliated Hospital of Nanjing Medical University (No. [2024]KY005-01). Informed consent was obtained from the legal guardians of each participant involved in the study. The study was registered in the National Medical Research Registration and Filing System (No. MR-32-24-025608).
Data collection
Demographic and clinical data were collected upon admission. All laboratory and imaging investigations were performed at the time of admission, following a standardized protocol. The duration of glucocorticoid use was defined as the total days of systemic therapy administered during hospitalization for the current RMPP episode.
The MP PCR testing was performed using a TaqMan quantitative reverse transcription PCR (qRT-PCR) assay kit (No. 20213400256, Sansure Biotech Inc., Changsha, China). Serum concentrations of YKL-40 and IL-37 were quantified using enzyme-linked immunosorbent assay (ELISA) kits (catalog numbers JN20159 and JN19667; Shanghai Jining Industrial Co., Ltd., Shanghai, China). The mRNA expression levels of YKL-40 and IL-37 in peripheral blood mononuclear cells (PBMCs) were measured by qRT-PCR using apparatus model No. 96a (Hangzhou Borui Technology Co., Ltd., Hangzhou, China).
We calculated the sample size based on the events per variable (EPV) metric. In our cohort, the incidence of RMPP was 0.5. Given our intention to include 3–5 predictors and setting an EPV of 10, we calculated the required sample size through the following formula:
The nomogram’s development followed a structured, multi-step process. Candidate variables, chosen for their clinical relevance and prior literature findings, underwent univariate analysis. Statistically significant variables (P<0.05) were then incorporated into multivariate analysis to identify independent predictors. A nomogram was constructed based on the results of the final multivariate model.
Statistical analysis
Statistical analyses were performed using R software (version 4.2.0). Categorical variables are presented as counts and percentages, while continuous variables are expressed as medians and interquartile ranges (IQRs). Pearson’s Chi-squared test was used to compare categorical variables. For normally distributed continuous data, comparisons between groups were carried out using the independent samples t-test; non-normally distributed data were compared using the Mann-Whitney U test. Logistic regression analysis was employed to calculate odds ratios (ORs) and 95% confidence intervals (CIs). The performance of the nomogram was evaluated by receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA).
Results
Demographic and clinical characteristics
A total of 210 children with MPP were enrolled in this study, of whom 105 were classified into RMPP. As shown in Table 1, there were no significant differences between the RMPP and NRMPP groups in terms of age, sex distribution, and disease duration prior to enrollment. The RMPP group demonstrated significantly longer hospital stays and fever durations compared to the NRMPP group (P<0.05). Rates of oxygen therapy, bronchoscopy, and plastic bronchitis were significantly higher in the RMPP group. The proportion of children receiving glucocorticoid treatment was also higher among RMPP cases, with a correspondingly longer duration of glucocorticoid administration. No significant differences were observed in the clinical symptoms between groups. Although fever incidence was comparable, the maximum body temperature was significantly elevated in the RMPP group relative to the NRMPP group.
Table 1
| Characteristics | RMPP (n=105) | NRMPP (n=105) | t (Z) or χ2 | P value |
|---|---|---|---|---|
| Sex | 0.02 | >0.99 | ||
| Male | 45 | 44 | ||
| Female | 60 | 61 | ||
| Age (years) | 7.0 (5.0, 9.0) | 7.0 (5.0, 8.0) | −0.19 | 0.85 |
| Disease course prior to enrollment (days) | 7.0 (5.0, 8.0) | 7.0 (6.0, 10.0) | −1.99 | 0.050 |
| Fever duration (days) | 8.0 (7.0, 8.5) | 5.0 (3.0, 6.0) | −9.54 | <0.001* |
| Maximum body temperature (℃) | 39.1 (39.0, 39.6) | 39.0 (38.6, 39.5) | −3.24 | 0.001* |
| Length of hospital stays (days) | 8.0 (8.0, 10.0) | 6.0 (6.0, 7.0) | −9.64 | <0.001* |
| Oxygen therapy | 11 (10.48) | 1 (0.95) | 8.84 | 0.003* |
| Bronchoscopy | 70 (66.67) | 23 (21.90) | 42.63 | <0.001* |
| Frequency of glucocorticoid use | 104 (99.05) | 95 (90.48) | 7.77 | 0.01* |
| Duration of glucocorticoid use (days) | 7.0 (5.0, 8.0) | 4.0 (3.0, 5.0) | −7.88 | <0.001* |
| Plastic bronchitis | 42 (40.00) | 13 (12.38) | 21.55 | <0.001* |
| Clinical symptoms | ||||
| Fever | 105 (100.00) | 100 (95.24) | 7.05 | 0.06 |
| Cough | 105 (100.00) | 105 (100.00) | – | – |
| Sputum | 48 (45.71) | 44 (41.90) | 0.31 | 0.67 |
| Wheezing | 6 (5.71) | 4 (3.81) | 0.42 | 0.52 |
| Shortness of breath | 8 (7.62) | 2 (1.90) | 4.04 | 0.050 |
| Chest pain | 2 (1.90) | 0 (0.00) | 2.79 | 0.50 |
| Imaging findings | ||||
| Lobar consolidation | 64 (60.95) | 31 (29.52) | 20.93 | <0.001* |
| Pleural effusions | 9 (8.57) | 1 (0.95) | 7.68 | 0.02* |
| Unilateral lobar infiltration | 71 (67.62) | 78 (74.29) | 1.13 | 0.36 |
| Bilateral lobar infiltration | 29 (27.62) | 15 (14.29) | 5.64 | 0.03* |
| Interstitial infiltration | 10 (9.52) | 15 (14.29) | 1.14 | 0.39 |
Data are presented as median (interquartile range), n or n (%). * indicates a statistically significant difference (P<0.05). MPP, Mycoplasma Pneumoniae pneumonia; NRMPP, non-RMPP; RMPP, refractory Mycoplasma pneumoniae pneumonia.
Imaging finds
RMPP group exhibited significantly higher frequencies of lobar consolidation (60.95% vs. 29.52%, P<0.001), pleural effusions (8.57% vs. 0.95%, P=0.02), and bilateral lobar infiltration (27.62% vs. 14.29%, P=0.03) compared to the NRMPP group (Table 1). No significant differences were found in unilateral lobar infiltration and Interstitial infiltration.
Laboratory test
The neutrophil-to-lymphocyte ratio (NLR) and neutrophil-monocyte-to-lymphocyte ratio (NMLR) were significantly higher in the RMPP group compared to the NRMPP group (P<0.05), whereas lymphocyte counts were lower in RMPP children (Table 2). There was no significant difference in the ratio of C-reactive protein to procalcitonin (CRP/PCT) between the two groups. Serum levels of both YKL-40 and IL-37 were significantly elevated in the RMPP group (P<0.05). Quantitative qRT-PCR revealed an increased YKL-40 mRNA expression in the RMPP group (P<0.05), while IL-37 mRNA expression showed marginal significance (P=0.05).
Table 2
| Variables | RMPP (n=105) | NRMPP (n=105) | t (Z) or χ2 | P value |
|---|---|---|---|---|
| WBC (109/L) | 7.87±2.69 | 8.21±3.34 | –0.81 | 0.42 |
| NEU (109/L) | 4.79±2.16 | 4.85±2.68 | –0.19 | 0.85 |
| LYN (109/L) | 2.17 (1.64, 2.76) | 2.44 (1.88, 3.33) | –2.76 | 0.01* |
| MON (109/L) | 0.51±0.22 | 0.54±0.22 | –0.89 | 0.38 |
| EOS (109/L) | 0.04 (0.01, 0.08) | 0.04 (0.02, 0.12) | –0.52 | 0.60 |
| Hb (g/L) | 122.44±8.89 | 123.47±7.83 | –0.89 | 0.38 |
| PLT (109/L) | 297.15±96.42 | 315.47±93.78 | –1.4 | 0.16 |
| NLR | 2.09 (1.42, 2.89) | 1.69 (1.08, 2.51) | –2.43 | 0.02* |
| PLR | 135.56 (96.90, 171.60) | 118.77 (97.75, 150.10) | –1.65 | 0.10 |
| MLR | 0.24±0.12 | 0.22±0.11 | 1.71 | 0.09 |
| NMLR | 2.35 (1.62, 3.14) | 1.91 (1.25, 2.75) | –2.44 | 0.02* |
| CRP/PCT | 215.38 (102.79, 430.74) | 223.91 (89.09, 500.00) | –0.46 | 0.65 |
| YKL-40 (ng/mL) | 133.48 (101.96, 193.73) | 117.99 (88.18, 174.38) | –2.68 | 0.01* |
| IL-37 (pg/mL) | 77.90±35.75 | 87.74±31.21 | –2.14 | 0.03* |
| YKL-40 mRNA | 5.78 (1.86, 15.63) | 4.13 (1.61, 10.34) | –2.13 | 0.03* |
| IL-37 mRNA | 7.40 (3.20, 10.79) | 8.63 (3.90, 15.93) | –1.99 | 0.050 |
Data are presented as mean ± standard deviation or median (interquartile range). * indicates a statistically significant difference (P<0.05). CRP, C-reactive protein; EOS, eosinophils; Hb, hemoglobin; IL-37, interleukin-37; LYN, lymphocyte; MLR, mononuclear-to-lymphocyte ratio; MON, monocyte; MPP, Mycoplasma pneumoniae pneumonia; NEU, neutrophils; NLR, neutrophil to lymphocyte ratio; NRMPP, non-RMPP; PCT, procalcitonin; PLR, platelet-to-lymphocyte ratio; PLT, platelet; RMPP, refractory Mycoplasma pneumoniae pneumonia; WBC, white blood cell.
Logistic regression analysis
Based on clinical practice and analytical findings, 13 variables were included in the multivariate logistic regression model. The results demonstrated that fever duration (OR =2.153, 95% CI: 1.609–2.882, P<0.001), duration of glucocorticoid use (OR =1.556, 95% CI: 1.167–2.076, P<0.001), and YKL-40 (OR =1.014, 95% CI: 1.005–1.023, P=0.001) were independent risk factors for RMPP (Table 3).
Table 3
| Variable | OR (95% CI) | P value |
|---|---|---|
| Fever duration | 2.153 (1.609–2.882) | <0.001* |
| Maximum body temperature | 0.467 (0.224–0.971) | 0.050 |
| Oxygen therapy | 0.387 (0.021–7.166) | 0.52 |
| Duration of glucocorticoid use | 1.556 (1.167–2.076) | 0.003* |
| Plastic bronchitis | 0.417 (0.142–1.223) | 0.11 |
| Lobar consolidation | 0.516 (0.210–1.265) | 0.15 |
| Pleural effusions | 0.098 (0.003–2.937) | 0.18 |
| Bilateral lobar infiltration | 0.376 (0.121–1.168) | 0.09 |
| LYN | 1.108 (0.735–1.670) | 0.62 |
| NLR | 1.099 (0.777–1.556) | 0.59 |
| YKL-40 (ng/mL) | 1.014 (1.005–1.023) | 0.003* |
| IL-37 (pg/mL) | 0.991 (0.977–1.005) | 0.23 |
| YKL-40 mRNA | 1.041 (0.982–1.103) | 0.18 |
* indicates a statistically significant difference (P<0.05). CI, confidence interval; IL-37, interleukin-37; LYN, lymphocyte; NLR, neutrophil to lymphocyte ratio; OR, odds ratio.
Nomogram prediction model
A nomogram prediction model incorporating these three risk factors was constructed (Figure 1). Each factor was assigned a weighted score, with the total score of 160. The predicted probability of RMPP ranged from 0.1 to 0.9, with higher scores correlating with increased risk. The model demonstrated excellent discrimination, with an area under the curve (AUC) of 0.92 (95% CI: 0.88–0.96) (Figure 2). The optimal cutoff for the nomogram’s predicted probability was determined to be 0.51, with a corresponding Youden’s index of 0.71. Calibration analysis and the Hosmer-Lemeshow test (P>0.99) indicated good agreement between predicted and observed outcomes (Figure 3). DCA further confirmed that the nomogram provided clinical net benefit across a wide threshold range (0.04–0.94) (Figure 4).
Discussion
The incidence of RMPP has been increased in China in recent years (11). RMPP is typically characterized by prolonged disease course, poor response to treatment, and multiple complications. Early recognition of RMPP is the focus of current research. Previous reports have demonstrated that persistent fever during treatment is associated with excessive inflammatory response and prolonged disease course in RMPP patients (15). Consistent with these findings, we found that children with RMPP exhibited longer fever duration, higher peak body temperature, and extended hospital stays, aligning with Chen et al.’s report (16). Furthermore, both the frequency and duration of glucocorticoid therapy were higher in the RMPP group, reflecting a stronger immune response and the potential benefit of immunosuppressive treatment (17).
The pathogenesis of RMPP is multifactorial, involving complex immune responses and cytokine dysregulation. YKL-40, a cytokine involved in adaptive Th2 immune responses, was significantly elevated in the serum and PBMCs of RMPP patients compared to NRMPP, consistent with Huang et al.’s findings in bronchoalveolar lavage fluid (18). This suggests that an increased YKL-40 expression may be a risk factor for RMPP. Conversely, IL-37, an anti-inflammatory cytokine, was found at lower serum levels and reduced mRNA expression in PBMCs of RMPP children compared to NRMPP for the first time. This finding implies that IL-37 may play a protective, anti-inflammatory role in MP infection, meriting further investigation.
Plastic bronchitis is a serious lung complication characterized by the formation of bronchial casts that obstruct airways. Shen et al. (19) reported that the rates of unilateral pulmonary consolidation and plastic bronchitis are significantly higher in children with RMPP compared to those with NRMPP. Consistently, our study found significantly elevated incidences of lobar consolidation (60.95% vs. 29.52%) and plastic bronchitis (40% vs. 12.38%) among RMPP patients. Although these factors were not identified as significant predictors of RMPP in our regression analysis, the distinct imaging manifestations remain valuable reference points for the differentiation and early recognition of RMPP.
Inflammatory and immune cells, along with their secreted mediators, have been established as common biomarkers for the assessment and prediction of infectious diseases (6). In this study, levels of LYN, NLR and NMLR differed between groups; however, none showed a significant association with RMPP in the regression analysis. Moreover, although prior study has linked a high CRP/PCT ratio with MP infection (20), we found no significant difference in this ratio between RMPP and NRMPP groups, indicating limited predictive value for RMPP.
Multivariate analysis identified prolonged fever duration, extended glucocorticoid therapy, and elevated serum YKL-40 as independent risk factors for RMPP. Given the clinical challenge of distinguishing RMPP from NRMPP due to overlapping symptoms and laboratory findings, we developed a nomogram incorporating these factors to predict RMPP risk. This model demonstrated strong predictive performance with an AUC of 0.92, outperforming previous models (6-8). Furthermore, DCA further established the superior clinical utility of our nomogram by confirming a significant net benefit over alternative strategies, a critical assessment not previously reported in this context.
This study is not without limitations. The single-center design and limited sample size, together with potential selection bias from the enrollment criteria, restrict the generalizability of the findings. Further, the 6-month study period may not fully capture potential year-round epidemiological variations in MPP. Crucially, our nomogram was not externally validated. While it demonstrated great performance, its predictive accuracy must be confirmed in larger, multicenter populations before it can be recommended for widespread clinical use.
Conclusions
The nomogram constructed based on fever duration, duration of glucocorticoid use, and YKL-40 demonstrates reliable predictive accuracy and practicality. It can be used for quantitative risk assessment of RMPP, providing valuable reference for the early identification of children with RMPP.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the TRIPOD reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-407/rc
Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-407/dss
Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-407/prf
Funding: This study was supported by
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-407/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The Second People’s Hospital of Changzhou, the Third Affiliated Hospital of Nanjing Medical University (No. [2024]KY005-01). Informed consent was obtained from the legal guardians of each participant involved in the study.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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