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A 6-Year-Old Boy With Cough, Mucositis, and Vesiculobullous Skin Lesions

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

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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Article Information

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 (xyy81924@126.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.

References
1.
Ramien  ML .  Reactive infectious mucocutaneous eruption: Mycoplasma pneumoniae–induced rash and mucositis and other parainfectious eruptions.   Clin Exp Dermatol. 2021;46(3):420-429. doi:10.1111/ced.14404PubMedGoogle ScholarCrossref
2.
Adler  H , Gould  S , Hine  P ,  et al; NHS England High Consequence Infectious Diseases (Airborne) Network.  Clinical features and management of human monkeypox: a retrospective observational study in the UK.   Lancet Infect Dis. 2022;22(8):1153-1162. doi:10.1016/S1473-3099(22)00228-6PubMedGoogle ScholarCrossref
3.
Meyer Sauteur  PM , Theiler  M , Buettcher  M , Seiler  M , Weibel  L , Berger  C .  Frequency and clinical presentation of mucocutaneous disease due to Mycoplasma pneumoniae infection in children with community-acquired pneumonia.   JAMA Dermatol. 2020;156(2):144-150. doi:10.1001/jamadermatol.2019.3602PubMedGoogle ScholarCrossref
4.
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
5.
Ramien  ML , Bahubeshi  A , Lara-Corrales  I ,  et al.  Blistering severe cutaneous adverse reactions in children: proposal for paediatric-focused clinical criteria.   Br J Dermatol. 2021;185(2):447-449. doi:10.1111/bjd.20063PubMedGoogle ScholarCrossref
6.
Ramien  ML , Bruckner  AL .  Mucocutaneous eruptions in acutely ill pediatric patients—think of Mycoplasma pneumoniae (and other infections) first.   JAMA Dermatol. 2020;156(2):124-125. doi:10.1001/jamadermatol.2019.3589PubMedGoogle ScholarCrossref
7.
Song  A , Nicholson  C , Maguiness  S .  Recurrent reactive infectious mucocutaneous eruption (RIME) in two adolescents triggered by several distinct pathogens including SARS-CoV-2 and influenza A.   Pediatr Dermatol. 2021;38(5):1222-1225. doi:10.1111/pde.14780PubMedGoogle ScholarCrossref
8.
Ryder  CY , Pedersen  EA , Mancuso  JB .  Reactive infectious mucocutaneous eruption secondary to SARS-CoV-2.   JAAD Case Rep. 2021;18:103-105. doi:10.1016/j.jdcr.2021.10.007PubMedGoogle ScholarCrossref
9.
Sloan  B .  This month in JAAD Case Reports: March 2022: reactive infectious mucocutaneous eruption secondary to SARS-CoV-2.   J Am Acad Dermatol. 2022;86(3):530-531. doi:10.1016/j.jaad.2021.12.031PubMedGoogle ScholarCrossref
10.
Maredia  H , Eseonu  A , Grossberg  AL , Cohen  BA .  Recurrent Mycoplasma pneumoniae–associated reactive infectious mucocutaneous eruption responsive to systemic steroids: a case series.   JAAD Case Rep. 2021;11:139-143. doi:10.1016/j.jdcr.2021.03.009PubMedGoogle ScholarCrossref
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