A previously healthy 6-year-old boy taking no regular medications presented to the emergency department with persistent fever and cough for 15 days. Six days prior to presentation, multiple vesiculobullous lesions appeared on his palms and soles. Three days later, he developed erythema; vesicles and erosions on his face, trunk, and limbs; erosions on his lips and oral mucosa; eyelid swelling; and blisters on his anal mucosa.
On presentation, his temperature was 38.7 °C (101.7 °F); heart rate, 125/min; blood pressure, 98/50 mm Hg; and oxygen saturation, 98% on room air. Physical examination revealed bilateral exudative conjunctivitis and white exudates on his tongue, posterior pharynx, and buccal mucosa. Erosions with overlying dried blood were noted around his eyes, lips, and anal mucosa. He had targetoid erythematous papules on his face and vesiculobullous lesions on his torso and extremities (Figure). Auscultation of his lungs revealed bilateral crackles. Laboratory testing showed a white blood cell count of 15 000/μL (82% neutrophils); erythrocyte sedimentation rate, 39 mm/h; and C-reactive protein level, 57.1 mg/L. A computed tomography scan of the chest revealed bilateral lower lobe infiltrates. Azithromycin (10 mg/kg daily, intravenously) was started.
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Reactive infectious mucocutaneous eruption (RIME)
B. Obtain Mycoplasma pneumoniae IgM and IgG levels
The key to the correct diagnosis is recognition that the combination of pneumonia; oral, ocular, and anal mucositis; and cutaneous lesions in a child is suggestive of RIME, which is most commonly associated with Mycoplasma pneumoniae infection.1 Behçet disease (choice A) is incorrect because this condition is not typically associated with pneumonia, and the patient did not have a history of recurrent oral and genital ulcerations. Patients with Kawasaki syndrome typically do not have cough or vesiculobullous lesions, so performing an echocardiogram (choice C) is not necessary. Monkeypox (choice D) typically presents with vesicles or pustules, followed by scabbing and desquamation.2
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Corresponding Author: Yuanyuan Xiao, MD, Department of Dermatology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56 S Lishi Rd, Xicheng District, Beijing 100045, China (email@example.com).
Published Online: November 18, 2022. doi:10.1001/jama.2022.19628
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient’s mother for providing permission to share the patient’s information.
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