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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.
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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
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Corresponding Author: Franco Falcone, MD, Department of Medicine, State University of New York Downstate Medical Center, 450 Clarkson Ave, MSC-50, Brooklyn, NY 11203 (firstname.lastname@example.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.
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