[Skip to Content]
[Skip to Content Landing]

Oral and Penile Lesions in a Young Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 28-year-old man presented to the emergency department with diffuse oral lesions, fever, and nonproductive cough for 1 week. He was diagnosed with herpes simplex virus (HSV) and discharged home with acyclovir. Two days later, he returned with worsening oral lesions, painful phonation, poor oral intake, odynophagia, and new painful penile lesions. He denied any abdominal pain, diarrhea, rectal bleeding, weight loss, arthralgia, fatigue, vision changes, or skin rashes. He reported a similar episode of widespread oral lesions 18 months earlier that was less severe and self-resolving. He had no other medical conditions, took no medications, and was sexually monogamous with his wife, who was asymptomatic.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

M pneumoniae–induced rash and mucositis (MIRM)

C. Prescribe oral azithromycin

The key to the correct diagnosis is the elevated M pneumoniae IgM titers in a patient with a nonproductive cough and 2 sites of mucosal lesions. Although Crohn disease and systemic lupus erythematosus can present with oral lesions, the patient’s lack of associated gastrointestinal or musculoskeletal symptoms make these diagnoses unlikely. Since the patient is HIV-negative and immunocompetent, oral candidiasis is unlikely.

M pneumoniae infections are often asymptomatic but can also present as upper respiratory tract infections, bronchitis, or pneumonia. Less commonly, patients with M pneumoniae infection can have mucocutaneous manifestations. MIRM is an extremely rare complication of M pneumoniae infection (exact incidence unknown) and often is mistaken for Stevens-Johnson syndrome or HSV-associated erythema multiforme. Typically, MIRM occurs in older children or adolescents and involves the oral, ocular, and genitourinary mucosal surfaces in 94%, 82%, and 63% of cases, respectively. Skin involvement is typically sparse and occurs in an acral distribution.1

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity
Article Information

Corresponding Author: Franco Falcone, MD, Department of Medicine, State University of New York Downstate Medical Center, 450 Clarkson Ave, MSC-50, Brooklyn, NY 11203 (franco.falcone@nychhc.org).

Published Online: June 24, 2019. doi:10.1001/jama.2019.7804

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Christopher Torsitano, BS, and Barrett Torre, BA (College of Medicine, State University of New York, Downstate Medical Center), for help with the literature review; Silvia Mancebo, MD, and Miriam Lieberman, MD (Department of Dermatology, State University of New York, Downstate Medical Center), for help with photograph acquisition; and Samy McFarlane, MD, MPH, MBA (Department of Internal Medicine, State University of New York, Downstate Medical Center), for help with the overall content and editorial review. None of these individuals received compensation for their contributions. We also thank the patient for providing permission to share his information.

References
1.
Canavan  TN, Mathes  EF, Frieden  I, Shinkai  K.  Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review.  J Am Acad Dermatol. 2015;72(2):239-245. doi:10.1016/j.jaad.2014.06.026PubMedGoogle ScholarCrossref
2.
Loens  K, Ieven  M.  Mycoplasma pneumoniae: current knowledge on nucleic acid amplification techniques and serological diagnostics.  Front Microbiol. 2016;7:448. doi:10.3389/fmicb.2016.00448PubMedGoogle ScholarCrossref
3.
Canadian Agency for Drugs and Technologies in Health.  Serum IgM and Molecular Tests for Mycoplasma pneumoniae Detection: A Review of Diagnostic Test Accuracy, Clinical Effectiveness, Cost-Effectiveness, and Guidelines. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2015.
4.
Lee  SC, Youn  YS, Rhim  JW, Kang  JH, Lee  KY.  Early serologic diagnosis of Mycoplasma pneumoniae pneumonia: an observational study on changes in titers of specific IgM antibodies and cold agglutinins.  Medicine (Baltimore). 2016;95(19):e3605. doi:10.1097/MD.0000000000003605PubMedGoogle ScholarCrossref
5.
Lee  WJ, Huang  EY, Tsai  CM,  et al.  Role of serum Mycoplasma pneumoniae IgA, IgM, and IgG in the diagnosis of Mycoplasma pneumoniae–related pneumonia in school-age children and adolescents.  Clin Vaccine Immunol. 2017;24(1):e00471-e16. doi:10.1128/CVI.00471-16PubMedGoogle ScholarCrossref
6.
Sillis  M.  The limitations of IgM assays in the serological diagnosis of Mycoplasma pneumoniae infections.  J Med Microbiol. 1990;33(4):253-258. doi:10.1099/00222615-33-4-253PubMedGoogle ScholarCrossref
7.
Pereyre  S, Goret  J, Bébéar  C.  Mycoplasma pneumoniae: current knowledge on macrolide resistance and treatment.  Front Microbiol. 2016;7:974. doi:10.3389/fmicb.2016.00974PubMedGoogle ScholarCrossref
8.
Taylor-Robinson  D, Bébéar  C.  Antibiotic susceptibilities of mycoplasmas and treatment of mycoplasmal infections.  J Antimicrob Chemother. 1997;40(5):622-630. doi:10.1093/jac/40.5.622PubMedGoogle ScholarCrossref
9.
Martire  B, Foti  C, Cassano  N, Buquicchio  R, Del Vecchio  GC, De Mattia  D.  Persistent B-cell lymphopenia, multiorgan disease, and erythema multiforme caused by Mycoplasma pneumoniae infection.  Pediatr Dermatol. 2005;22(6):558-560. doi:10.1111/j.1525-1470.2005.00140.xPubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Topics
State Requirements