Two pediatric cases of influenza B-induced rash and mucositis: Stevens-Johnson syndrome or expansion of the Mycoplasma pneumoniae-induced rash with mucositis (MIRM) spectrum?

Reactive Infectious Mucocutaneous Eruption Associated With Klebsiella pneumoniae

Reactive infectious mucocutaneous eruption (RIME) is a clinical syndrome characterized by mucosal and cutaneous manifestations triggered by various infectious agents. Herein, we describe a case of an 11-year-old girl who presented with RIME, with significant genital involvement, associated with a urinary tract infection caused by Klebsiella pneumoniae. This case highlights the importance of examining the genital mucosa in RIME and the need for increased awareness of RIME among physicians.

COVID-19 associated severe mucocutaneous blistering eruptions: A case series

Mucocutaneous eruptions are associated with numerous infectious processes and can present as erythema multiforme (EM), reactive infectious mucocutaneous eruption (RIME), Stevens Johnson syndrome (SJS), or toxic epidermal necrolysis (TEN). Limited reports have detailed the association of these eruptions with SARS-CoV-2 infection. We present a series of eight cases of severe mucocutaneous blistering eruptions associated with SARS-CoV-2 infection. A retrospective case series was performed at six tertiary medical centers from March 1, 2020 to August 1, 2022. Inclusion criteria were met with a clinical diagnosis of EM, RIME, SJS, or TEN and a positive SARS-CoV-2 test (rapid antigen or polymerase chain reaction) less than 4 weeks prior to onset of dermatologic manifestation. Data was collected at time of each patient encounter. Eight patients met criteria with six pediatric patients (<18 years of age) having a median age of 15 years and two adult patients (>18 years of age) having a median age of 36 years. Patients were found to have a clinical diagnosis of RIME in 85.7% of cases. Oral mucosal involvement was the most common clinical finding (100%), followed by ocular (50.0%), urogenital (50.0%), and skin (37.5%) involvement. Evaluation did not reveal any additional infectious triggers in four patients. Evidence of possible concurrent or previous infectious triggers were identified in four patients. This case series highlights the development of severe mucocutaneous eruptions in association with COVID-19 infection, as well as the potential contributing role of concurrent or prior infections.

Ocular involvement in Mycoplasma induced rash and mucositis: A systematic review of the literature

Mycoplasma pneumoniae induced rash and mucositis (MIRM) is a relatively newly identified clinical entity which is characterized by mucocutaneous manifestations in the setting of Mycoplasma infection. Though a clinically distinct disease, MIRM exists on a diagnostic continuum with entities including erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, and the recently described reactive infectious mucocutaneous eruption (RIME). In this systematic review, we discuss published findings on the epidemiology, clinical manifestations, diagnosis, and management of MIRM, with an emphasis on ocular disease. Lastly, we discuss some of the most recent developments and challenges in characterizing MIRM with respect to the related diagnosis of RIME.

[Viral exanthems in children]

Virale und paravirale Exantheme sind die häufigsten Exantheme des Kindesalters, die auch meist zu einer Vorstellung in der Praxis inklusive der Notaufnahme führen. Die Kenntnis der verschiedenen Krankheitsbilder ist entscheidend für die adäquate Diagnostik und Betreuung der kleinen Patient:innen, die entsprechende Aufklärung der Familie und ggf. das Minimieren des Infektionsrisikos. In der aktuellen Arbeit werden die kürzlich beschriebenen „reactive infectious mucocutaneous eruptions“ (RIME) und das „pediatric inflammatory multisystem syndrome“ (PIMS) vorgestellt. Zusätzlich werden wir einige atypische Manifestationen des Gianotti-Crosti-Syndroms und der Hand-Fuß-Mund-Erkrankung – wie z. B. die mit Mollusken assoziierte „Gianotti-Crosti-like reaction“ und das „eczema coxsackium“ – erläutern.

Mycoplasma pneumoniae-induced rash and mucositis: A case report

Mycoplasma pneumoniae-induced rash and mucositis (MIRM) is a recently defined clinical entity characterized by pneumonia caused by M. pneumoniae with associated mucositis and frequent cutaneous lesions of a characteristic pattern. Although often similar in presentation, MIRM has distinct clinical and histologic features that are different from erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis. We report a case of MIRM in a nine-year-old boy.

Recurrent reactive infectious mucocutaneous eruption (RIME) in two adolescents triggered by several distinct pathogens including SARS-CoV-2 and influenza A

Reactive infectious mucocutaneous eruption (RIME) was proposed as new terminology to encompass postinfectious mucocutaneous eruptions. The term includes all postinfectious mucocutaneous eruptions such as the widely reported Mycoplasma pneumoniae-induced rash and mucositis (MIRM). Very few reports in the literature regarding recurrent RIME are found. We present two adolescent cases of recurrent RIME that involve SARS-CoV-2 and influenza A where the latter is a newly reported infectious trigger; in both patients, the initial episode was likely triggered by Mycoplasma pneumoniae (MP) infection.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review of Diagnosis and Management

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare diseases that are characterized by widespread epidermal necrosis and sloughing of skin. They are associated with significant morbidity and mortality, and early diagnosis and treatment is critical in achieving favorable outcomes for patients. In this scoping review, Excerpta Medica dataBASE and PubMed were searched for publications that addressed recent advances in the diagnosis and management of the disease. Multiple proteins (galectin 7 and RIP3) were identified that are promising potential biomarkers for SJS/TEN, although both are still in early phases of research. Regarding treatment, cyclosporine is the most effective therapy for the treatment of SJS, and a combination of intravenous immunoglobulin (IVIg) and corticosteroids is most effective for SJS/TEN overlap and TEN. Due to the rare nature of the disease, there is a lack of prospective, randomized controlled trials and conducting these in the future would provide valuable insights into the management of this disease.

Kawasaki disease mimickers

BACKGROUND

Kawasaki disease (KD) is an acute systemic vasculitis that predominantly affects patients younger than 5 years. In the absence of an available, affordable diagnostic test, detailed clinical history and physical examination are still fundamental to make a diagnosis.

METHODS

We present five representative cases with KD-like presentations: systemic onset juvenile idiopathic arthritis, mycoplasma-induced rash and mucositis, staphylococcal scalded skin syndrome, BCGosis, and the recently described multisystemic inflammatory syndrome in children (MIS-C) associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) virus.

RESULTS

Rash, fever, and laboratory markers of inflammation can be present in several childhood diseases that may mimic KD.

CONCLUSION

The term 'Kawasaki syndrome' instead of 'Kawasaki disease' may be more appropriate. Physicians should consider an alternative diagnosis that may mimic KD, particularly considering MIS-C during the present pandemic, as an aggressive diagnostic and therapeutic approach is needed.

A fatal case of toxic epidermal necrolysis combined with vanishing bile duct syndrome and hemophagocytic lymphohistiocytosis

This case report describes a case of fatal Toxic Epidermal Necrolysis complicated by both vanishing bile duct syndrome and hemophagocytic lymphohistiocytosis due to Influenza B infection. Here we highlight the potential for complex morbidity secondary to underlying autoimmune hypersensitivity. Furthermore, the stepwise progression of these pathologies is noted, with the initial epidermal lesions first progressing to cholestatic injury and then subsequently to the hematologic manifestations.

Current Pharmacogenetic Perspective on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Adverse drug reactions are a public health issue that draws widespread attention, especially for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) which have high mortality and lack of efficacious treatment. Though T-cell-mediated HLA-interacted immune response has been extensively studied, our understanding of the mechanism is far from satisfactory. This review summarizes infection (virus, bacterial, and mycoplasma infection), an environmental risk factor, as a trigger for SJS/TEN. The mutations or polymorphisms of drug metabolic enzymes, transporters, receptors, the immune system genes, and T-cell-mediated apoptosis signaling pathways that contribute to SJS/TEN are discussed and summarized. Epigenetics, metabolites, and mobilization of regulatory T cells and tolerogenic myeloid precursors are emerged directions to study SJS/TEN. Ex vivo lymphocyte transformation test has been exploited to aid in identifying the causative drugs. Critical questions on the pathogenesis of SJS/TEN underlying gene polymorphisms and T cell cytotoxicity remain: why some of the patients carrying the risky genes tolerate the drug and do not develop SJS/TEN? What makes the skin and mucous membrane so special to be targeted? Do they relate to skin/mucous expression of transporters? What is the common machinery underlying different HLA-B alleles associated with SJS/TEN and common metabolites?

Ocular involvement in recurrent infectious mucocutaneous eruption (RIME): a variation on a theme

We present 2 cases of pediatric patients with reactive infectious mucocutaneous eruption with ophthalmic involvement. In both cases, the disease processes behaved similarly to that seen in patients with Mycoplasma pneumoniae-induced rash and mucositis. Visual outcomes were good.

Clinical features of recurrent Mycoplasma pneumoniae-induced rash and mucositis

BACKGROUND/OBJECTIVES

The characteristics of patients experiencing recurrent Mycoplasma pneumoniae-induced rash and mucositis (MIRM) are not well understood. We aimed to characterize patients with recurrent disease by comparing the demographics, skin and mucosal involvement, seasonality, and treatment to those with single episodes (isolated MIRM).

METHODS

This retrospective case series screened all patients seen by our dermatology inpatient consult service from September 2014 to March 2020. Cases were selected based on laboratory and clinical criteria that confirmed a diagnosis of MIRM.

RESULTS

We identified 13 patients with MIRM: 5 who experienced recurrence (38%) and 8 with isolated, single episodes without recurrence. Mean age was 13.6 years for initial episodes in the recurrent patients compared to 11.7 in patients with isolated episodes. All 5 recurrent MIRM patients were male (compared with 75% of isolated MIRM patients) and predominantly Black (60%, compared with 25%). Most episodes overall (isolated and recurrent) occurred from the months of October to February. Recurrences after initial MIRM episode had less severe skin and mucosal findings, often involving only one mucous membrane, less frequent need for hospital admission, and shorter duration of hospital stay. Prophylactic treatments and treatments beyond supportive care were of unclear value.

CONCLUSIONS

Some characteristics of MIRM differ between patients with recurrent and isolated disease. Clinicians should be aware of the potential for recurrence, which occurred in 38% of our cohort. Although recurrences after initial MIRM episode tended to be less severe, there is still potential for prolonged hospitalizations with recurrent episodes. More evidence is needed regarding effective preventive and treatment regimens in patients with recurrent MIRM.

Adenoviral-induced rash and mucositis: Expanding the spectrum of reactive infectious mucocutaneous eruption

Mucocutaneous eruptions associated with respiratory pathogens, specifically Mycoplasma pneumoniae (MP), has recently been described as a MIRM (MP-induced rash and mucositis). The term reactive infectious mucocutaneous eruption (RIME) has been proposed, since non-MP pathogens may also cause a similar rash and mucositis. We report two cases with clinical manifestations suggestive of MIRM/RIME, both with documented adenovirus infection.

Mycoplasma pneumoniae-Induced Rash and Mucositis in a Previously Healthy Man: A Case Report and Brief Review of the Literature

We describe a case of a 33-year-old-male with Mycoplasma pneumoniae-induced rash and mucositis and review the literature on this newly described syndrome.

Reactive infectious mucocutaneous eruption: Mycoplasma pneumoniae-induced rash and mucositis and other parainfectious eruptions

Mycoplasma pneumoniae-induced rash and mucositis is the most accurate diagnosis for patients with blistering mucocutaneous disease provoked by an infection. Recent literature suggests expansion of the name is required, as other infections have caused a clinically similar presentation. This review provides a concise update on current understanding of M. pneumoniae-induced rash and mucositis and other reactive infectious mucocutaneous eruptions.

Recurrent reactive infectious mucocutaneous eruption (RIME): Insights from a child with three episodes

Reactive infectious mucocutaneous eruption (RIME) was recently proposed to replace the term Mycoplasma pneumoniae (MP)-induced rash and mucositis to account for the fact that non-MP pathogens may also cause rash and mucositis. In this report, we describe a unique case of recurrent RIME featuring a total of three episodes. As two of the episodes demonstrated contemporaneous infection with MP and group A streptococcus or influenza B, this case lends further support to use of the term RIME. In addition, although RIME typically involves at least two mucous membranes, this case shows that recurrent episodes may fall into the rare exception in which mucositis is limited to one site.

Exanthematous Eruptions in Children

Childhood exanthems are commonly encountered by pediatricians in the hospital and the office. In the last several decades, we have seen a shift in the epidemiology of many of these diseases. After being deemed eliminated at the turn of 21st century, measles has experienced a resurgence secondary to falling vaccination rates, raising public health concerns. A new variant of hand, foot, and mouth disease caused by coxsackievirus A6 has been associated with more widespread and atypical disease, which can present diagnostic challenges to clinicians. Parvovirus B19, which is traditionally associated with fifth disease, is also the leading cause of papular purpuric gloves and socks syndrome, a rare condition with which providers may be unfamiliar. Since the introduction of routine vaccination, there has been a shift in the epidemiology and clinical presentation of primary varicella and herpes zoster. Finally, the recently described phenomenon of Mycoplasma pneumoniae-induced rash and mucositis will be discussed. [Pediatr Ann. 2020;49(3):e116-e123.].