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Bilateral Limbus-Sparing Conjunctivitis in a Boy With Rash and Pneumonia

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

An adolescent boy presented to the hospital with bilateral eye redness, an erythematous chest rash, lip blistering, and worsening sore throat for 2 days while undergoing a 10-day outpatient treatment course of ciprofloxacin and trimethoprim-sulfamethoxazole for community-acquired pneumonia. He complained of a cough, sore throat, and ocular itching. He denied prior ocular history and reported no visual changes. He had no significant medical history aside from documented allergies to β-lactam, macrolide, and cephalosporin antibiotics resulting in rashes, angioedema, and hives.

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Mycoplasma pneumoniae–induced rash and mucositis

B. Initiate course of topical ophthalmic antibiotics and corticosteroids

The leading diagnosis was pneumonia due to M pneumoniae, and the patient’s antibiotic regimen was switched to doxycycline and clindamycin. Given this patient’s presentation with mucosal erosions in the setting of pneumonia, his younger age, and evanescent mild skin involvement, a diagnosis of M pneumoniae–induced rash and mucositis (MIRM) was favored over M pneumoniae–induced Stevens-Johnson syndrome (SJS), which can have a similar presentation but is characterized by more severe mucocutaneous involvement.

Because of the favorable prognosis of MIRM and its associated ocular manifestations,1 initiation of topical ophthalmic therapy consisting of antibiotic prophylaxis and mild corticosteroids (choice B) is the first recommended course. Systemic corticosteroids (choice A) are not recommended as the next step because the patient had a mild presentation and did not exhibit persistent conjunctivitis despite topical therapy. Amniotic membrane transplantation (choice C) is not recommended because it is an aggressive treatment reserved for cases of biopsy-proven or highly suspected SJS; this treatment carries substantial (albeit temporary) morbidity in conscious patients, given the reduction of vision due to amniotic membranes overlying the cornea and discomfort caused by symblepharon rings in the fornices.2 Antibiotic cessation (choice D) would not be the preferred answer because although drug-induced SJS or toxic epidermal necrolysis was on the differential diagnosis, given the patient’s medication allergies, the lack of characteristic skin sloughing argued against this diagnosis.2,3

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Article Information

Corresponding Author: James Chodosh, MD, MPH, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles St, Boston, MA 02152 (james_chodosh@meei.harvard.edu).

Published Online: September 12, 2019. doi:10.1001/jamaophthalmol.2019.3137

Conflict of Interest Disclosures: Dr Chodosh has received personal fees from Shire. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this 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 Scholar
2.
Saeed  HN, Chodosh  J.  Ocular manifestations of Stevens-Johnson syndrome and their management.  Curr Opin Ophthalmol. 2016;27(6):522-529. doi:10.1097/ICU.0000000000000312PubMedGoogle Scholar
3.
Kohanim  S, Palioura  S, Saeed  HN,  et al.  Stevens-Johnson syndrome/toxic epidermal necrolysis—a comprehensive review and guide to therapy: I: systemic disease.  Ocul Surf. 2016;14(1):2-19. doi:10.1016/j.jtos.2015.10.002PubMedGoogle Scholar
4.
Waites  KB, Talkington  DF.  Mycoplasma pneumoniae and its role as a human pathogen.  Clin Microbiol Rev. 2004;17(4):697-728. doi:10.1128/CMR.17.4.697-728.2004PubMedGoogle Scholar
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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):e00471-16. doi:10.1128/CVI.00471-16PubMedGoogle Scholar
6.
Santos  RP, Silva  M, Vieira  AP, Brito  C.  Mycoplasma pneumoniae-induced rash and mucositis: a recently described entity  [published online August 22, 2017].  BMJ Case Rep. doi:10.1136/bcr-2017-220768PubMedGoogle Scholar
7.
Zão  I, Ribeiro  F, Rocha  V, Neto  P, Matias  C, Jesus  G.  Mycoplasma pneumoniae-associated mucositis: a recently described entity.  Eur J Case Rep Intern Med. 2018;5(11):000977.PubMedGoogle Scholar
8.
Grieb  A, Kaderschabek  N, Orasche  C,  et al.  Mycoplasma pneumoniae-associated mucositis with cutaneous involvement—a case report.  J Dtsch Dermatol Ges. 2019;17(2):184-185.PubMedGoogle Scholar
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Vujic  I, Shroff  A, Grzelka  M,  et al.  Mycoplasma pneumoniae-associated mucositis—case report and systematic review of literature.  J Eur Acad Dermatol Venereol. 2015;29(3):595-598. doi:10.1111/jdv.12392PubMedGoogle Scholar
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