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Atypical presentation of mycoplasma pneumoniae-associated mucositis syndrome with no skin involvement in a young adult

Authors

Lauren Larkin, MS31; Oltion Mesi, MD2, 1. Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, 2. Department of Internal Medicine, Cleveland Clinic, Cleveland, OH.

Introduction

Mucositis is a rare extrapulmonary manifestation that affects up to ~20% of patients with mycoplasma pneumoniae infection1. M. pneumoniae-induced rash and mucositis (MIRM) typically includes ocular and mucocutaneous eruptions, with no skin involvement reported in only ~30% of cases1,2,4.

Case Presentation

We present a 24-year-old otherwise healthy male admitted with bilateral conjunctival inflammation along with oral and urethral ulcerations, sparing the rest of the skin and perianal regions. He reported a 6-day history of malaise, fever (maximum 103°F), cough, headache, and diarrhea, and had been treated for a suspected bacterial respiratory illness with azithromycin. The patient presented without significant improvement in symptoms and the development of mucosal ulcerations and eye redness.

On initial presentation, the patient was febrile and tachycardic with leukocytosis (17.3) and elevated ESR (84) and CRP (11.7). A sepsis workup was initiated and he was started on broad-spectrum antibiotics with vancomycin/zosyn/acyclovir/fluconazole. Chest x-ray revealed no abnormalities. Blood cultures, respiratory viral panel, Legionella urinary antigen, Streptococcus pneumoniae, gastrointestinal polymerase chain reaction (PCR) panel, HIV, and Gonorrhea/Chlamydia testing were negative.

On exam, there were multiple prominent erythematous lesions appreciated within upper and lower vermilion border in various stages of healing with some eschars. Ulceration was present at the urethral meatus with shallow erosion extending 1-2 mm circumferentially onto glans penis. No apparent rashes were noted. It was determined by rheumatology and ophthalmology that the patient's ocular manifestations were not consistent with uveitis and the oral ulcers were not of typical morphology for Behcet's disease. A more extensive infectious workup was done with the following labs being negative: Syphilis IgG with confirmation, Herpes Simplex Virus (HSV) 1/2, enterovirus PCR, Staphylococcus aureus PCR, and Hepatitis B and C virus.

Mycoplasma pneumoniae IgM was positive (5.21), which uncovered the likely etiology for the patient's signs and symptoms. Given the lack of improvement with azithromycin, he was treated with IV levofloxacin for 5 days. The patient was discharged with rapid improvement in clinical condition on levofloxacin, prednisone, and moxifloxacin/bacitracin/prednisone ophthalmic suspension.

Discussion

Mycoplasma pneumoniae is most commonly associated with community-acquired pneumonia, however, only 25% of patients experience extrapulmonary complications1,6. MIRM most commonly presents in the pediatric population3,5,8. The proposed diagnostic criteria for MIRM, include: less than 10% body surface area affected, involvement of two or more mucosal sites, scattered atypical targets, and clinical and laboratory evidence of atypical pneumonia1,7. These key distinguishing features are useful in ruling out more severe diagnoses, such as Stevens-Johnson syndrome, which was a concern in this case given the patient's lack of response to azithromycin. It is important to distinguish between MIRM and mycoplasma-associated Stevens-Johnson syndrome (MASJS) to direct appropriate treatment. This case highlights a challenging, rare presentation of MIRM in an adult with ocular, oral, and urethral involvement and sparing of the skin.

References

  1. Canavan, T. N., Mathes, E. F., Frieden, I., & Shinkai, K. (2015). Mycoplasma pneumoniae–induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. Journal of the American Academy of Dermatology, 72(2), 239-245.
  2. Varghese, C., Sharain, K., Skalski, J., & Ramar, K. (2014). Case Report: Mycoplasma pneumonia-associated mucositis. BMJ case reports, 2014.
  3. Alcántara-Reifs, C. M., & García-Nieto, A. V. (2016). Mycoplasma pneumoniae–associated mucositis. Canadian Medical Association Journal, 188(10), 753-75
  4. Poddighe, D., & Bruni, P. (2017). Mycoplasma pneumoniae-induced rash and mucositis (MIRM): an unusual mild skin rash associated with severe mucosal involvement. BMJ case reports, 2017.
  5. Alter, S. J., & Stringer, B. (1990). Mycoplasma pneumoniae infections associated with severe mucositis. Clinical pediatrics, 29(10), 602-604.
  6. Vujic, I., Shroff, A., Grzelka, M., Posch, C., Monshi, B., Sanlorenzo, M., ... & Rappersberger, K. (2015). Mycoplasma pneumoniae-associated mucositis–case report and systematic review of literature. Journal of the European Academy of Dermatology and Venereology, 29(3), 595-598.
  7. Song, H., Huang, J. T., & Tan, J. K. (2018). Mycoplasma-induced Rash and Mucositis in a Father and Son: A Case Report. The Pediatric infectious disease journal, 37(7), e205-e206.
  8. Figueira-Coelho, J., Lourenço, S., Pires, A. C., Mendonca, P., & Malhado, J. A. (2008). Mycoplasma pneumoniae-associated mucositis with minimal skin manifestations. American journal of clinical dermatology, 9(6), 399-403.

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