Let this Rash not Fox You: Mycoplasma-Induced Rash and Mucositis
Year: 2024
Type: article
Study design: Case Report
Abstract: Fever with a rash usually presents as a diagnostic conundrum due to the varied etiology and administration of many drugs by the time the patient presents. The management strategy depends on the disease, for example, anti-microbial or supportive therapy in bacterial and viral illnesses but with systemic steroids in severe cutaneous adverse reaction (SCAR) and connective tissue diseases.[1] Oral mucosa is most commonly involved (94%), followed by ocular (82%) and urogenital mucosa (63%).[2] A 29-year-old male was admitted with fever for 12 days, rash for 5 days, redness with a burning sensation in the mouth and throat with difficulty in swallowing for 3 days, and shortness of breath for 1 day. The fever was high grade, intermittent in nature, and associated with chills. There was a history of intake of two doses of tablet cefixime on day 6 of fever, following which the rash started to emerge over the upper back, progressing to the chest, neck, face, abdomen, upper limbs, and palms. He complained of a burning sensation in his mouth and throat, causing difficulty in swallowing both solids and liquids for the past 3 days. The breathlessness lasted for one day, was present at rest, and was associated with severe bouts of dry cough exacerbated by speaking. The patient was looking ill with breathlessness at rest. There was fever (102° C), tachycardia (124 beats/minute), and tachypnoea (46/minute) with a thoraco-abdominal pattern of respiration. In addition, all the accessory muscles of respiration were at work. Bilateral sub-mandibular lymph nodes were enlarged and tender. There was intense erythema of bilateral conjunctiva [Figure 1a and b]. All mucosa of the oral cavity as well as the pharynx were intensely inflamed with few superficial erosions on the hard palate [Figure 1c-e]. A blanchable maculopapular rash was seen on the face, neck, trunk, upper limbs, and palms [Figure 2a and b]. The lower limbs and soles were spared. The rash was non-tender with negative Nikolsky sign. There were no petechiae or eschars. The total leucocyte count was 12100 per cubic millimeter with relative neutrophilia (89%). The peripheral blood smear showed a shift to the left pattern but with no toxic granules or vacuoles. There were no atypical lymphocytes or eosinophilia. All other routine blood tests including culture were normal. Chest X-ray did not reveal any abnormality; however, HRCT-chest revealed multiple peripheral patchy ground glass opacities suggestive of atypical pneumonia [Figure 3]. Polymerase chain reaction (PCR) as well as IgM antibodies for Mycoplasma pneumoniae were positive. In view of the aforementioned findings, the patient was diagnosed as a case of M. pneumoniae induced rash and mucositis (MIRM) with atypical pneumonia and was started on a tablet 500 mg per day azithromycin. The patient showed rapid improvement over the next 48 hours with resolution of tachypnea, tachycardia, fever, and cough. The rash resolved without any tell-tale signs. The mucosal erythema of the oral cavity and pharynx resolved earlier than that of the eyes.Figure 1: (a and b) Intense erythema of bilateral palpebral conjunctiva (c-e) Erythema of the mucosa of the oral cavity with few superficial erosions on the hard palateFigure 2: (a and b) Blancheable maculopapular rash over trunkFigure 3: High-resolution computed tomography chest (HRCT) showing multiple peripheral patchy ground glass opacities (white arrow) suggestive of atypical infective etiologyDepending on the type of rash, Canavan et al. classified MIRM into three types.[3] MIRM-sine-rash presents with no significant skin involvement; classic-MIRM presents with sparse skin involvement; and severe-MIRM presents with widespread skin involvement. The pathogenesis of MIRM is believed to be due to either cross-reacting auto-antibodies aimed at the glycolipid antigens of M. pneumoniae or direct cytotoxicity.[4] The spectrum of cutaneous involvement varies from the erythema multiformae minor/major to SJS/toxic epidermal necrolysis, macules, and morbilliform eruptions.[5] There are no clear guidelines for the management of MIRM, but most of the reported cases have been treated with macrolide antibiotics, systemic steroids, intravenous immunoglobulins (IVIG), and supportive care.[6] Although antibiotics have been shown to limit the progression and severity of pulmonary disease, it is unclear whether they help in the resolution of mucocutaneous eruptions. Systemic steroids and IVIG have been proven to have a role in reducing the long-term sequelae consisting of mucous membrane scarring, contracture, and adhesions.[7] Timely management with macrolide antibiotics is life-saving. Informed consent was obtained from the patient for research and publication. The institutional ethical committee waived ethical approval for the case. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the parent has given consent for images and other clinical information to be reported in the journal. The parent understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed. Data availability statement Nil. Author contribution P.D: Inception of the manucript, collection of data, analysis of data, editing the manuscript and correspondence; G.S: Collection of data, editing the manuscript; G.K.S: Editing and proof reading; N.K.D: Collection of data; S.M: Editing the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Authors: Pankaj Das, Ganesh Saravagi, Gautam K. Singh, Nikunja K. Das, Sahjid Mukhida
Language: English
Subfield: Microbiology
Field: Immunology and Microbiology
Domain: Life Sciences
Open Access status: diamond
OpenAlex ID: W4402579998