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Subahi G, Waheeb S, Binmadi N, Almazrooa S, Akeel S, Öhman J, Dafar A. Erythema multiforme-like lip presentation in pemphigus vulgaris patients: a multicenter case series. BMC Oral Health 2023; 23:952. [PMID: 38041037 PMCID: PMC10693153 DOI: 10.1186/s12903-023-03665-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/14/2023] [Indexed: 12/03/2023] Open
Abstract
Pemphigus vulgaris (PV) is a chronic autoimmune mucocutaneous blistering disease. Autoantibodies are directed against desmogleins, leading to the formation of intraepithelial bullae. PV, as with other autoimmune mucocutaneous disorders of the oral cavity, presents diagnostic and therapeutic challenges. Approximately 50-70% of cases present first with oral lesions. The lesions commonly start as vesicles or bullae that rapidly rupture, leading to erosions and ulcerations. The palatal, gingival, buccal, and labial mucosa are the most commonly affected sites. Oral PV can mimic several other diseases that cause mucosal erosions and/or ulcerations, including erythema multiforme (EM). EM is an acute, immune-mediated, self-limited hypersensitivity condition primarily associated with herpes simplex infection. Oral lesions can be variable, but a very characteristic presentation with labial hemorrhagic erosions, ulcerations and crusting is commonly seen. In this case series, we present six cases of PV: one male patient and five female patients whose ages ranged from 34 to 65 years old. All patients presented with hemorrhage and crusting of the lips in addition to multiple intraoral erosions and ulcerations. Three patients presented with oral and skin lesions. All patients underwent biopsies, and a diagnosis of PV was confirmed. All patients were treated with steroids (topical and systemic) and variable steroid-sparing agents. This case series emphasizes that oral PV may be misdiagnosed as EM in a subgroup of patients who present with persistent lip hemorrhage and crusting. Therefore, a comprehensive history, clinical examination and incisional biopsies should be considered in such patients.
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Affiliation(s)
- Ghidaa Subahi
- Oral Medicine and Pathology Saudi Board Program, Jeddah, Saudi Arabia
| | | | - Nada Binmadi
- Oral Diagnostic Sciences Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Soulafa Almazrooa
- Oral Diagnostic Sciences Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sara Akeel
- Oral Diagnostic Sciences Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jenny Öhman
- Department of Oral Medicine and Pathology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Amal Dafar
- Department of Oral Medicine and Pathology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Oral and Maxillofacial Surgery, King Fahad General Hospital, Jeddah, Saudi Arabia.
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2
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Alrashdan MS, Arzmi MH, Ahmad Kamil WN, Al Kawas S, Leao JC. Immune-mediated oral mucosal pathology: a comprehensive review and update for clinicians. Part I. Ital J Dermatol Venerol 2023; 158:408-418. [PMID: 37916401 DOI: 10.23736/s2784-8671.23.07676-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
The oral mucosa can be involved in a wide variety of mucocutaneous conditions that may present primarily in the mouth or affect other cutaneous or mucosal sites. Many of these conditions are immune mediated and typically present as inflammatory mucosal pathology. Patients experiencing such conditions usually seek medical evaluation and treatment due to the associated pain and discomfort and occasionally taste disturbance or dysphagia and the overall deterioration in the oral health-related quality of life. These conditions share some common features and there could be some overlapping in their clinical presentation, which can lead to delays in diagnosis and proper management of patients. Clinicians dealing with such disorders, including dermatologists, need to be aware of the oral manifestations of mucocutaneous conditions, their clinical features, underlying mechanisms, diagnostic approaches, and treatment options, as well as the recent advances in the research on these conditions. This review provides a comprehensive, evidence-based reference for clinicians, with updated insights into a group of immune mediated conditions known to cause oral mucosal pathology. Part one will cover oral lichen planus, erythema multiforme and systemic lupus erythematosus, while part two will cover pemphigus vulgaris and mucous membrane pemphigoid, recurrent aphthous stomatitis, in addition to the less common disorders linear IgA disease, dermatitis herpetiformis and epidermolysis bullosa.
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Affiliation(s)
- Mohammad S Alrashdan
- Department of Oral and Craniofacial Health Sciences, College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates -
- Department of Oral Medicine and Oral Surgery, Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan -
| | - Mohd H Arzmi
- Kulliyyah of Dentistry, International Islamic University Malaysia, Pahang, Malaysia
- Cluster of Cancer Research Initiative IIUM (COCRII), International Islamic University Malaysia, Pahang, Malaysia
- Jardin Pharma Berhad, Selangor, Malaysia
| | - Wan N Ahmad Kamil
- Kulliyyah of Dentistry, International Islamic University Malaysia, Pahang, Malaysia
- Cluster of Cancer Research Initiative IIUM (COCRII), International Islamic University Malaysia, Pahang, Malaysia
- Faculty of Dentistry, MARA University of Technology (UiTM), Selangor, Malaysia
| | - Sausan Al Kawas
- Department of Oral and Craniofacial Health Sciences, College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Jair C Leao
- Department of Clinics and Preventive Dentistry, Federal University of Pernambuco, Recife, Brazil
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3
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Haseeb A, Elhusseiny AM, ElSheikh RH, Tahboub MA, Kwan JT, Saeed HN. Ocular involvement in Mycoplasma induced rash and mucositis: A systematic review of the literature. Ocul Surf 2023; 28:1-10. [PMID: 36396020 DOI: 10.1016/j.jtos.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/12/2022] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Abid Haseeb
- Department of Ophthalmology, Nazareth Hospital, Philadelphia, PA, USA; Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Abdelrahman M Elhusseiny
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA; Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Reem H ElSheikh
- Department of Ophthalmology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Mohammad A Tahboub
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - James T Kwan
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Hajirah N Saeed
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA; Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA; Department of Ophthalmology, Loyola University Medical Center, Maywood, IL, USA.
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4
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Trombetta A, De Nardi L, Barbi E, Declich V, Dall'Amico R. Don't just look at the surface: when mucosa tells more than the skin. Arch Dis Child Educ Pract Ed 2022; 107:265-267. [PMID: 33504471 PMCID: PMC9304110 DOI: 10.1136/archdischild-2020-319195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 12/30/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Andrea Trombetta
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Laura De Nardi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy.,Department of Pediatrics, Institute for Maternal and Child Health IRCCS 'Burlo Garofolo', Trieste, Italy
| | - Valentina Declich
- Department of Pediatrics, AAS 5 Ospedale 'Santa Maria degli Angeli', Pordenone, Friuli-Venezia Giulia, Italy
| | - Roberto Dall'Amico
- Department of Pediatrics, AAS 5 Ospedale 'Santa Maria degli Angeli', Pordenone, Friuli-Venezia Giulia, Italy
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5
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Kang SA, Khalaf SA, Nelson T. Immunoglobulin A vasculitis induced by atypical pneumonia infection with Chlamydophila pneumonia. IDCases 2022; 30:e01624. [PMID: 36193106 PMCID: PMC9526174 DOI: 10.1016/j.idcr.2022.e01624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/24/2022] [Indexed: 11/26/2022] Open
Abstract
Infections are a common trigger for IgA vasculitis. Among the bacteria that cause atypical pneumonia, Mycoplasma pneumoniae infection has strongly been associated with IgA vasculitis, with Chlamydophila pneumoniae reported with IgA vasculitis in only one case. Though IgA vasculitis is a self-limiting disease, patients with infection-related vasculitis have shown to benefit from early identification and treatment with antimicrobial therapy. Here, we report a case of IgA vasculitis due to C. pneumoniae infection in a 19-year-old male who presented with an acute onset of rash, that was later followed by symptoms of cough and fever.
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6
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Silverberg K, Lauck K, Van Sweringen J, Hafeez Z. Rapidly Progressive Oral Ulceration in a 12-year-old Girl. Pediatr Rev 2021; 42:e48-e50. [PMID: 34850177 DOI: 10.1542/pir.2019-0283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Kyle Lauck
- McGovern Medical School at UTHealth, Houston, TX
| | | | - Zoabe Hafeez
- McGovern Medical School at UTHealth, Houston, TX
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7
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Volkers SM, Meisel C, Terhorst-Molawi D, Burbach GJ, Schürmann D, Suttorp N, Sander LE. Clonal expansion of CD4 +CD8 + T cells in an adult patient with Mycoplasma pneumoniae-associated Erythema multiforme majus. Allergy Asthma Clin Immunol 2021; 17:17. [PMID: 33568212 PMCID: PMC7877069 DOI: 10.1186/s13223-021-00520-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 01/27/2021] [Indexed: 01/15/2023] Open
Abstract
Background Erythema multiforme (EM) is an acute, immune-mediated mucocutaneous disease, most often preceded by herpes simplex virus (HSV) infection or reactivation. Mycoplasma pneumoniae (Mp) is considered the second major trigger of EM and is often associated with an atypical and more severe presentation of disease, characterized by prominent mucosal involvement. However, contrary to HSV-associated Erythema multiforme (HAEM), immunological mechanisms of Mp-associated EM remain unclear. Case presentation We present the case of a 50-year-old male patient presenting with community-acquired pneumonia (CAP) and erythema multiforme majus (EMM). Acute Mp infection was diagnosed by seroconversion, with no evidence of HSV infection as a cause of EMM. We performed immune phenotyping of blister fluid (BF) and peripheral blood (PB) T cells and detected a clonally expanded TCRVβ2+ T cell population that was double positive for CD4 and CD8, and expressed the cytotoxic markers granulysin and perforin. This CD4+CD8+ population comprised up to 50.7% of BF T cells and 24.9% of PB T cells. Two years prior to the onset of disease, the frequency of PB CD4+CD8+T cells had been within normal range and it gradually returned to baseline levels with the resolution of symptoms, suggesting an involvement of this population in EMM disease pathophysiology. Conclusions This report is the first to provide a phenotypic description of lesional T cells in Mp-associated EMM. Characterizing the local immune response might help to address pathophysiological questions and warrants further systematic research.
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Affiliation(s)
- Sarah M Volkers
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Meisel
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Immunology, Labor Berlin-Charité Vivantes GmbH, Berlin, Germany
| | - Dorothea Terhorst-Molawi
- Department of Dermatology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Guido J Burbach
- Dermatology/Dermato-Oncology Out-Patient Clinic, Vivantes Ambulatory Health Care Centers Berlin-Spandau, Berlin, Germany
| | - Dirk Schürmann
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Norbert Suttorp
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,German Center for Lung Research (DZL), Berlin, Germany
| | - Leif E Sander
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany. .,German Center for Lung Research (DZL), Berlin, Germany.
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8
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Trčko K. Imiquimod-Associated Erythema Multiforme. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2020. [DOI: 10.15570/actaapa.2020.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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9
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Liu L, Wang Y, Sun J, Wang W, Hou J, Wang X. Case Report: Clinical and Immunological Features of a Chinese Cohort With Mycoplasma-Induced Rash and Mucositis. Front Pediatr 2020; 8:402. [PMID: 32793529 PMCID: PMC7387509 DOI: 10.3389/fped.2020.00402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/11/2020] [Indexed: 11/21/2022] Open
Abstract
Dermatological disorders are the most common extrapulmonary complications of Mycoplasma pneumoniae, of which Mycoplasma-induced rash and mucositis (MIRM) has recently been proposed to be a separate diagnostic entity. MIRM could easily be misdiagnosed as atypical Stevens-Johnson syndrome by clinicians due to the unawareness of this rare disease. We retrospectively reviewed the inpatient database from Jan. 2016 to Dec. 2019 of the Children's Hospital of Fudan University. In total, five patients (mean age 5.5 years, three male) matched the diagnostic criteria of MIRM. All patients had scattered lesions and more than two sites of mucosal involvement. The serum IgA level of three patients was higher than normal. Two patients had a significant decrease in peripheral blood CD3+ T and CD4+ T cells that improved with recovery. The percentage of TCRαβ+ CD4-CD8-T cells of Patient five was higher than normal. All patients received treatments with antibiotics and corticosteroids, 3 patients received intravenous immunoglobulin. Among five patients, three patients complained of dyspigmentation, and two patients had an uneventful recovery. MIRM is a separate entity with predominant mucosal involvement and excellent prognosis that more often affects younger patients. Excessive inflammatory reactions may lead to immune disorders, including lymphopenia and a redistribution of CD4+ T cells. We recommend that pneumonia accompanied by mucocutaneous eruptions, especially in young patients, should raise clinical suspicion of MIRM.
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Affiliation(s)
- Lipin Liu
- Department of Allergy and Clinical Immunology, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Wang
- Department of Allergy and Clinical Immunology, Children's Hospital of Fudan University, Shanghai, China
| | - Jinqiao Sun
- Department of Allergy and Clinical Immunology, Children's Hospital of Fudan University, Shanghai, China
| | - Wenjie Wang
- Department of Allergy and Clinical Immunology, Children's Hospital of Fudan University, Shanghai, China
| | - Jia Hou
- Department of Allergy and Clinical Immunology, Children's Hospital of Fudan University, Shanghai, China.,Department of Pediatrics, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Xiaochuan Wang
- Department of Allergy and Clinical Immunology, Children's Hospital of Fudan University, Shanghai, China
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10
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Triggers, clinical manifestations, and management of pediatric erythema multiforme: A systematic review. J Am Acad Dermatol 2019; 81:813-822. [PMID: 31331726 DOI: 10.1016/j.jaad.2019.02.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 02/20/2019] [Accepted: 02/24/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Erythema multiforme (EM) is an acute inflammatory mucocutaneous condition. EM is rarely described in children and infants. OBJECTIVE To investigate the triggers, clinical manifestations, and treatment of pediatric EM. METHODS Systematic literature review of pediatric EM. RESULTS After full-text article review, we included 113 articles, representing 580 patients. The mean age was 5.6 years, ranging 0.1-17 years. Infectious agents were the main triggers: herpes simplex virus (HSV) in 104 patients (17.9%) and Mycoplasma pneumoniae in 91 patients (15.7%). In total, 140 cases (24.1%) were drug-related and 89 cases (15.3%) had other triggers, such as vaccines (19 patients, 3.2%). In total, 229 patients had EM major (39.5%). Treatment was supportive care only (180 patients, 31.1%), systemic corticosteroids (115 patients, 19.8%), antivirals (85 patients, 14.6%), and antibiotics (66 patients, 11.3%), mostly macrolides (45 patients, 7.7%). Long-term sequelae were rare (1.3%). Pediatric EM was reported in 19 infants (3.2%). The main trigger was vaccination (9 patients). Infantile EM was EM major in 2 cases and EM minor in 17. Infants were less prone to develop EM major than older children (P < .01). Pediatric EM was recurrent in 83 cases (14.3%), which was triggered by HSV in 36 patients (61%). Recurrence affected older children. LIMITATIONS Potential confusion between Steven Johnson syndrome and EM major in addition to publication bias. CONCLUSION Pediatric EM is a rare disease, mainly triggered by infections. This condition can affect all mucosal surfaces, most commonly the oral mucosae. The diagnosis is clinical, and management relies on supportive care. Vaccines are a particular trigger in infants. Recurrent cases are most commonly linked to HSV. Dermatologists and pediatricians should be aware of this potentially recurrent and severe condition.
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11
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Chafranska L, Saunte DM, Behrendt N, Nygaard U, Christensen RJ, Sand C, Jemec GB. Pediatric toxic epidermal necrolysis treated successfully with infliximab. Pediatr Dermatol 2019; 36:342-345. [PMID: 30834560 DOI: 10.1111/pde.13778] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Successful management of toxic epidermal necrolysis (TEN) with tumor necrosis factor-α inhibitors has been described in adults. We present a case of a 7-year-old boy with infection-associated TEN, diagnosed by typical clinical and histopathological features, most likely caused by Mycoplasma pneumoniae. Treatment with a single dose of infliximab 5 mg/kg intravenously on day 5 after the onset of symptoms was followed by cessation of all blister formation over 3 days and complete resolution within a week. Sequelae were mild, consisting of postinflammatory hyperpigmentation and dry eyes.
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Affiliation(s)
- Lana Chafranska
- Departments of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
| | - Ditte M Saunte
- Departments of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
| | - Nille Behrendt
- Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark.,Pathology, Zealand University Hospital, Roskilde, Denmark
| | - Ulrikka Nygaard
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Carsten Sand
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark
| | - Gregor B Jemec
- Departments of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
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12
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de Risi-Pugliese T, Sbidian E, Ingen-Housz-Oro S, Le Cleach L. Interventions for erythema multiforme: a systematic review. J Eur Acad Dermatol Venereol 2019; 33:842-849. [PMID: 30680804 DOI: 10.1111/jdv.15447] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/19/2018] [Indexed: 11/28/2022]
Abstract
Treatment of erythema multiforme (EM) is not codified. We performed a systematic review of the effect of any topical or systemic treatment on time to healing and frequency of episodes with acute and chronic forms of EM in adults. Four databases (MEDLINE, CENTRAL, EMBASE and LILACS) and other sources were searched for articles published up to 20 March 2018. Randomized control trials (RCTs), observational studies and case series (n ≥ 10) were considered. From 1558 references, we included one RCT and six case series. The RCT (n = 20) showed a significant difference in complete remission of EM with continuous acyclovir vs. placebo over 6 months. One case series found a mean reduction in flare duration with thalidomide for recurrent EM (5.1 vs. 16.2 days; n = 20). Adverse events were poorly or not reported in included studies. Quality of life was never assessed. One limitation of our study is that we excluded the cases of isolated mucosal EM in order to prevent inclusion of Stevens-Johnson syndrome cases. In conclusion, there is low-level evidence for continuous acyclovir treatment for recurrent EM (one RCT). Evidence for other treatments is only based on retrospective case series. Results for thalidomide, in particular, encourage further research. Data concerning safety are insufficient. PROSPERO registration no. CRD42016053175.
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Affiliation(s)
- T de Risi-Pugliese
- Service de Dermatologie, AP-HP, Hôpital Henri Mondor, Créteil, France.,Service de Dermatologie et Allergologie, AP-HP, Hôpital Tenon, Paris, France
| | - E Sbidian
- Service de Dermatologie, AP-HP, Hôpital Henri Mondor, Créteil, France.,EA 7379 EpiDermE (Epidemiology in Dermatology and Evaluation of Therapeutics), Créteil, France.,INSERM CIC 1430, Paris-Est Creteil University, Creteil, France
| | - S Ingen-Housz-Oro
- Service de Dermatologie, AP-HP, Hôpital Henri Mondor, Créteil, France.,EA 7379 EpiDermE (Epidemiology in Dermatology and Evaluation of Therapeutics), Créteil, France
| | - L Le Cleach
- Service de Dermatologie, AP-HP, Hôpital Henri Mondor, Créteil, France.,EA 7379 EpiDermE (Epidemiology in Dermatology and Evaluation of Therapeutics), Créteil, France
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13
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
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14
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Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Current Perspectives on Erythema Multiforme. Clin Rev Allergy Immunol 2018; 54:177-184. [PMID: 29352387 DOI: 10.1007/s12016-017-8667-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Recognition and timely adequate treatment of erythema multiforme remain a major challenge. In this review, current diagnostic guidelines, potential pitfalls, and modern/novel treatment options are summarized with the aim to help clinicians with diagnostic and therapeutic decision-making. The diagnosis of erythema multiforme, that has an acute, self-limiting course, is based on its typical clinical picture of targetoid erythematous lesions with predominant acral localization as well as histological findings. Clinically, erythema multiforme can be differentiated into isolated cutaneous and combined mucocutaneous forms. Atypical erythema multiforme manifestations include lichenoid or granulomatous lesions as well as lesional infiltrates of T cell lymphoma and histiocytes. Herpes simplex virus infection being the most common cause, other infectious agents like-especially in children-Mycoplasma pneumoniae, hepatitis C virus, Coxsackie virus, and Epstein Barr virus may also trigger erythema multiforme. The second most frequently identified cause of erythema multiforme is drugs. In different studies, e.g., allopurinol, phenobarbital, phenytoin, valproic acid, antibacterial sulfonamides, penicillins, erythromycin, nitrofurantoin, tetracyclines, chlormezanone, acetylsalicylic acid, statins, as well as different TNF-α inhibitors such as adalimumab, infliximab, and etanercept were reported as possible implicated drugs. Recently, cases of erythema multiforme associated with vaccination, immunotherapy for melanoma, and even with topical drugs like imiquimod have been described. In patients with recurrent herpes simplex virus-associated erythema multiforme, the topical prophylactic treatment with acyclovir does not seem to prevent further episodes of erythema multiforme. In case of resistance to one virostatic drug, the switch to an alternative drug, and in patients non-responsive to virostatic agents, the use of dapsone as well as new treatment options, e.g., JAK-inhibitors or apremilast, might be considered.
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Affiliation(s)
- Marianne Lerch
- Allergy/Dermatology Unit, Department of Internal Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Carlo Mainetti
- Department of Dermatology, Bellinzona Regional Hospital, Bellinzona, Switzerland
| | | | - Thomas Harr
- Unité d'allergologie, Service d'immunologie et d'allergologie, Hôpitaux Universitaires de Genève HUG, Rue Micheli-du-Crest 24, CH-1211, Genève, Switzerland.
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15
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From HSV infection to erythema multiforme through autoimmune crossreactivity. Autoimmun Rev 2018; 17:576-581. [PMID: 29635075 DOI: 10.1016/j.autrev.2017.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/24/2017] [Indexed: 12/26/2022]
Abstract
Scientific and clinical data indicate that human herpes simplex virus 1 (HSV1) and, at a lesser extent, human herpes simplex virus 2 (HSV2) are factor(s) implicated in the development of erythema multiforme (EM). With a focus on oral EM, the present structured review of proteomic and epitope databases searched for the molecular basis that might link HSV1 and HSV2 infections to EM. It was found that a high number of peptides are shared between the two HSVs and human proteins related to the oral mucosa. Moreover, a great number of the shared peptides are also present in epitopes that have been experimentally validated as immunopositive in the human host. The results suggest the involvement of HSV infections in the induction of oral EM via a mechanism of autoimmune cross-reactivity and, in particular, highlight a potential major role for 180kDa bullous pemphigoid antigen and HSV1 infection in the genesis of crossreactions potentially conducive to EM.
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Ashton R, Wong KW, Weinstein M. Pediatric Lip Adhesion Following Bullous Erythema Multiforme and Review of Similar Oral Complications. J Cutan Med Surg 2018; 22:427-430. [DOI: 10.1177/1203475418761038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Erythema multiforme (EM) is a mucocutaneous disease most often associated with preceding herpes simplex virus or Mycoplasma pneumoniae infection. It is characterized by targetoid lesions occurring on the limbs and head and neck. Mucosal involvement can be extensive. Objective: We report a case of lip adhesion as a complication of EM in a child who required corrective surgery and review similar oral commissure complications. Methods: We completed a review of the literature for similar cases using PubMed and Medline. Conclusions and Relevance: We present the youngest report of lip adhesion due to striking mucositis related to EM. Sequelae of erythema multiforme can be significant, in our case requiring surgery. Meticulous oral hygiene should be encouraged when mucosal lesions are identified.
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Affiliation(s)
- Rosalind Ashton
- King’s College London, St John’s Institute of Dermatology, London, UK
| | - Karen W. Wong
- Division of Plastic Surgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Miriam Weinstein
- Division of Paediatric Medicine, Section of Dermatology, Hospital for Sick Children, Toronto, ON, Canada
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17
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Mimura T, Noma H, Yamagami S. Letter to the Editor: Bilateral Subconjunctival Hemorrhage in a 3-Year-Old Girl with Mycoplasma Pneumonia. Open Ophthalmol J 2017; 11:322-325. [PMID: 29299079 PMCID: PMC5725478 DOI: 10.2174/1874364101711010322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 10/28/2017] [Accepted: 11/07/2017] [Indexed: 11/22/2022] Open
Abstract
We report an unusual case of bilateral subconjunctival hemorrhage following mycoplasma pneumonia. A healthy 3-year-old girl developed bilateral subconjunctival hemorrhage at 4 days after the onset of fever and respiratory symptoms such as running nose, cough, and wheezing. Laboratory data were normal except for elevation of Mycoplasma pneumoniae antibodies. The patient was followed without treatment and the subconjunctival hemorrhage resolved in both eyes within two weeks. To the best of our knowledge, this is the first report of subconjunctival hemorrhage following mycoplasma pneumonia. Respiratory symptoms such as cough and wheezing may cause bilateral subconjunctival hemorrhage in infants.
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Affiliation(s)
- Tatsuya Mimura
- Department of Ophthalmology, Tokyo Women's Medical University Medical Center East, , Japan.,Department of Ophthalmology, University of Tokyo Graduate School of Medicine, , Japan
| | - Hidetaka Noma
- Department of Ophthalmology, Hachioji Medical Center, Tokyo Medical University, , Japan
| | - Satoru Yamagami
- Department of Ophthalmology, Tokyo Women's Medical University Medical Center East, , Japan.,Department of Ophthalmology, University of Tokyo Graduate School of Medicine, , Japan
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18
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Pavlos R, White KD, Wanjalla C, Mallal SA, Phillips EJ. Severe Delayed Drug Reactions: Role of Genetics and Viral Infections. Immunol Allergy Clin North Am 2017; 37:785-815. [PMID: 28965641 PMCID: PMC5702581 DOI: 10.1016/j.iac.2017.07.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Adverse drug reactions (ADRs) are a significant source of patient morbidity and mortality and represent a major burden to health care systems and drug development. Up to 50% of such reactions are preventable. Although many ADRs can be predicted based on the on-target pharmacologic activity, ADRs arising from drug interactions with off-target receptors are recognized. Off-target ADRs include the immune-mediated ADRs (IM-ADRs) and pharmacologic drug effects. In this review, we discuss what is known about the immunogenetics and pathogenesis of IM-ADRs and the hypothesized role of heterologous immunity in the development of IM-ADRs.
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Affiliation(s)
- Rebecca Pavlos
- Institute for Immunology and Infectious Diseases, Murdoch University, 6150 Murdoch, Western Australia, Australia
| | - Katie D White
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Celestine Wanjalla
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Simon A Mallal
- Institute for Immunology and Infectious Diseases, Murdoch University, 6150 Murdoch, Western Australia, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, 6150 Murdoch, Western Australia, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.
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19
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Bhoopalan SV, Chawla V, Hogan MB, Wilson NW, Das SU. Bullous Skin Manifestations of Mycoplasma pneumoniae Infection: A Case Series. J Investig Med High Impact Case Rep 2017; 5:2324709617727759. [PMID: 28959692 PMCID: PMC5593211 DOI: 10.1177/2324709617727759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 06/26/2017] [Accepted: 07/16/2017] [Indexed: 12/02/2022] Open
Abstract
Bullous skin lesions are uncommon in children. While it is well known that Mycoplasma infections are associated with papular skin manifestations, bullous skin lesions are not commonly reported. Mycoplasma pneumoniae is a very common bacterial pathogen causing respiratory tract infection in children and adults. We report 2 children with serology-confirmed Mycoplasma infection who were hospitalized for blistering skin lesions. Both of our patients responded well to corticosteroids and one of them required intravenous immunoglobulin. The aim of this case report is to raise awareness that Mycoplasma pneumoniae infection can present with bullous skin lesions, and to briefly review the pathophysiology, diagnosis, and management of the skin manifestation of Mycoplasma infection.
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Affiliation(s)
| | - Vonita Chawla
- University of Nevada, Las Vegas Campus, Las Vegas, NV, USA
| | | | - Nevin W Wilson
- University of Nevada, Las Vegas Campus, Las Vegas, NV, USA
| | - Samrat U Das
- University of Nevada, Las Vegas Campus, Las Vegas, NV, USA
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Chaudhry R, Ghosh A, Chandolia A. Pathogenesis of Mycoplasma pneumoniae: An update. Indian J Med Microbiol 2016; 34:7-16. [PMID: 26776112 DOI: 10.4103/0255-0857.174112] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Genus Mycoplasma, belonging to the class Mollicutes, encompasses unique lifeforms comprising of a small genome of 8,00,000 base pairs and the inability to produce a cell wall under any circumstances. Mycoplasma pneumoniae is the most common pathogenic species infecting humans. It is an atypical respiratory bacteria causing community acquired pneumonia (CAP) in children and adults of all ages. Although atypical pneumonia caused by M. pneumoniae can be managed in outpatient settings, complications affecting multiple organ systems can lead to hospitalization in vulnerable population. M. pneumoniae infection has also been associated with chronic lung disease and bronchial asthma. With the advent of molecular methods of diagnosis and genetic, immunological and ultrastructural assays that study infectious disease pathogenesis at subcellular level, newer virulence factors of M. pneumoniae have been recognized by researchers. Structure of the attachment organelle of the organism, that mediates the crucial initial step of cytadherence to respiratory tract epithelium through complex interaction between different adhesins and accessory adhesion proteins, has been decoded. Several subsequent virulence mechanisms like intracellular localization, direct cytotoxicity and activation of the inflammatory cascade through toll-like receptors (TLRs) leading to inflammatory cytokine mediated tissue injury, have also been demonstrated to play an essential role in pathogenesis. The most significant update in the knowledge of pathogenesis has been the discovery of Community-Acquired Respiratory Distress Syndrome toxin (CARDS toxin) of M. pneumoniae and its ability of adenosine diphosphate (ADP) ribosylation and inflammosome activation, thus initiating airway inflammation. Advances have also been made in terms of the different pathways behind the genesis of extrapulmonary complications. This article aims to comprehensively review the recent advances in the knowledge of pathogenesis of this organism, that had remained elusive during the era of serological diagnosis. Elucidation of virulence mechanisms of M. pneumoniae will help researchers to design effective vaccine candidates and newer therapeutic targets against this agent.
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Affiliation(s)
- R Chaudhry
- Department of Microbiology, AIIMS, New Delhi, India
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21
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Mycoplasma pneumoniae-Induced Mucocutaneous Rash: A New Syndrome Distinct from Erythema Multiforme? Report of a New Case and Review of the Literature. ACTAS DERMO-SIFILIOGRAFICAS 2016. [DOI: 10.1016/j.adengl.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Langley A, Anooshiravani N, Kwan S, Zeller J, Pope E. Erythema Multiforme in Children and Mycoplasma pneumoniae Aetiology. J Cutan Med Surg 2016; 20:453-7. [DOI: 10.1177/1203475416639018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Erythema multiforme (EM) in children is understudied and confused with Stevens-Johnson syndrome (SJS) despite their being separate diseases with unique aetiologies and clinical presentations. The goal of this study was to determine the prevalence of Mycoplasma pneumoniae in paediatric patients with EM minor, EM major (EMM), and SJS. This retrospective cohort at The Hospital for Sick Children accrued all cases of EM minor, EMM, and SJS from 1999 to 2013. Sixty-five cases were identified: 20 of EM minor, 23 of EMM, and 22 of SJS. Aetiologies were attributed in 58% of cases: 79% infection and 21% drug aetiology. Sixty-one percent of patients with EMM were M pneumoniae positive, compared with 14% of those with SJS and 22% of those with EM minor ( P < .01). M pneumoniae patients were older at presentation ( P = .03) and more frequently had sore throat ( P < .01) and atypical targets with central blistering ( P < .01). These findings suggest that M pneumoniae should be suspected and treated until laboratory confirmation becomes available in patients presenting with atypical target lesions with central blistering.
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Affiliation(s)
| | | | - Sarah Kwan
- The Hospital for Sick Children, Toronto, ON, Canada
| | - Jeanne Zeller
- St Joseph Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Elena Pope
- The Hospital for Sick Children, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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23
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Martínez-Pérez M, Imbernón-Moya A, Lobato-Berezo A, Churruca-Grijelmo M. Mycoplasma pneumoniae-Induced Mucocutaneous Rash: A New Syndrome Distinct from Erythema Multiforme? Report of a New Case and Review of the Literature. ACTAS DERMO-SIFILIOGRAFICAS 2016; 107:e47-51. [PMID: 27040303 DOI: 10.1016/j.ad.2015.09.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 09/13/2015] [Accepted: 09/20/2015] [Indexed: 10/22/2022] Open
Abstract
Respiratory tract infection due to Mycoplasma pneumoniae can provoke cutaneous and mucosal rashes, which have been classified within the spectrum of erythema multiforme or Stevens-Johnson syndrome. This classification is of therapeutic and prognostic importance and has generated intense debate in the literature. A recent systematic review of 202 cases of mucocutaneous rashes associated with M. pneumoniae infection concluded that these rashes might constitute a distinct entity, for which the term Mycoplasma-induced rash and mucositis was proposed. We describe a patient with acute M pneumoniae respiratory tract infection who presented mucosal and cutaneous lesions that were difficult to classify as erythema multiforme or Stevens-Johnson syndrome; the lesions were compatible with the proposed new disease.
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Affiliation(s)
- M Martínez-Pérez
- Servicio de Dermatología y Venereología, Hospital Severo Ochoa, Madrid, España.
| | - A Imbernón-Moya
- Servicio de Dermatología y Venereología, Hospital Severo Ochoa, Madrid, España
| | - A Lobato-Berezo
- Servicio de Dermatología y Venereología, Hospital Severo Ochoa, Madrid, España
| | - M Churruca-Grijelmo
- Servicio de Dermatología y Venereología, Hospital Severo Ochoa, Madrid, España
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24
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Winikor JM, Kennedy JC, Leonard MS, Dwyer-Matzky KE. A 14-Year-Old Boy With Mycoplasma pneumoniae-Associated Mucositis and Intracranial Hypertension. Clin Pediatr (Phila) 2016; 55:83-5. [PMID: 25667310 DOI: 10.1177/0009922815570615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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25
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Papatsiros VG, Athanasiou LV, Psalla D, Petridou E, Maragkakis GG, Papatsas I, Arsenakis I, Maes D. Erythema Multiforme Associated with Respiratory Disease in a Commercial Breeding Pig Herd. Viral Immunol 2015; 28:464-71. [PMID: 26266696 DOI: 10.1089/vim.2015.0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study describes an erythema multiforme (EM) in breeding sows, after their mixing in the group housing system. Sows at 30-35 days of gestation showed red and raised skin areas, depression, anorexia, fever, respiratory problems, and increased return to estrus. Blood and nasal samples from diseased sows were examined by quantitative polymerase chain reaction and enzyme-linked immunosorbent assay for respiratory pathogens. Hematological and biochemical analyses were performed on the blood samples. From diseased sows, vaginal swabs for microbiological examinations and samples at slaughterhouse for gross and microscopic examinations were collected. Samples from the complete gestation and lactation feed were examined for mycotoxins. All sampled sows were seropositive for Actinobacillus pleuropneumoniae (App) and porcine reproductive and respiratory syndrome virus (PRRSV). No viremia for PRRSV and porcine circovirus type 2 were detected. All nasal samples were positive for Streptococcus suis, one for Swine Influenza Virus and one for App, Hemophilus parasuis, and S. suis. In all vaginal swabs, Escherichia coli and Streptococcus spp. were detected. Diseased sows had moderate leukocytosis, mild anemia, and thrombocytopenia. No mycotoxins were detected in feed. Histopathological examination revealed increased vascularization of the superficial and middle dermis. EM was likely due to illness caused by viral and bacterial infections. This study suggests that stress caused by the sows' mixing might have triggered the problem.
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Affiliation(s)
- Vasileios G Papatsiros
- 1 Clinic of Medicine, Faculty of Veterinary Medicine, University of Thessaly , Karditsa, Greece
| | - Labrini V Athanasiou
- 1 Clinic of Medicine, Faculty of Veterinary Medicine, University of Thessaly , Karditsa, Greece
| | - Dimitra Psalla
- 2 Laboratory of Pathology, Faculty of Veterinary Medicine, Aristotle University of Thessaloniki , Thessaloniki, Greece
| | - Evanthia Petridou
- 3 Laboratory of Microbiology and Infectious Diseases, Faculty of Veterinary Medicine, Aristotle University of Thessaloniki , Thessaloniki, Greece
| | - Giorgos G Maragkakis
- 1 Clinic of Medicine, Faculty of Veterinary Medicine, University of Thessaly , Karditsa, Greece
| | | | - Ioannis Arsenakis
- 5 Department of Reproduction, Obstetrics, and Herd Health Unit Porcine Health Management, Faculty of Veterinary Medicine, Ghent University , Ghent, Belgium
| | - Dominiek Maes
- 5 Department of Reproduction, Obstetrics, and Herd Health Unit Porcine Health Management, Faculty of Veterinary Medicine, Ghent University , Ghent, Belgium
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Abstract
Annular, or ring-like, skin lesions are a distinctive cutaneous morphology. Dermatologic diagnosis is based on morphology and distribution, and therefore the generation of a differential diagnosis based on these criteria can lead to proper identification of an eruption. For many dermatologic conditions, considering a differential that includes infection, immune phenomenon, neoplastic process, physical etiology, and idiopathic process will assure that one thinks broadly and is likely to reveal the best diagnosis. Several of these categories are covered in this review of annular eruptions in children.
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28
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Mustafa MB, Porter SR, Smoller BR, Sitaru C. Oral mucosal manifestations of autoimmune skin diseases. Autoimmun Rev 2015; 14:930-51. [PMID: 26117595 DOI: 10.1016/j.autrev.2015.06.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 06/16/2015] [Indexed: 02/06/2023]
Abstract
A group of autoimmune diseases is characterised by autoantibodies against epithelial adhesion structures and/or tissue-tropic lymphocytes driving inflammatory processes resulting in specific pathology at the mucosal surfaces and the skin. The most frequent site of mucosal involvement in autoimmune diseases is the oral cavity. Broadly, these diseases include conditions affecting the cell-cell adhesion causing intra-epithelial blistering and those where autoantibodies or infiltration lymphocytes cause a loss of cell-matrix adhesion or interface inflammation. Clinically, patients present with blistering, erosions and ulcers that may affect the skin as well as further mucosal surfaces of the eyes, nose and genitalia. While the autoimmune disease may be suspected based on clinical manifestations, demonstration of tissue-bound and circulating autoantibodies, or lymphocytic infiltrates, by various methods including histological examination, direct and indirect immunofluorescence microscopy, immunoblotting and quantitative immunoassay is a prerequisite for definitive diagnosis. Given the frequency of oral involvement and the fact that oral mucosa is the initially affected site in many cases, the informed practitioner should be well acquainted with diagnostic and therapeutic aspects of autoimmune dermatosis with oral involvement. This paper reviews the pathogenesis and clinical presentation of these conditions in the oral cavity with a specific emphasis on their differential diagnosis and current management approaches.
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Affiliation(s)
- Mayson B Mustafa
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104 Freiburg, Germany; Oral medicine section, Department of Oral and Maxillofacial Surgery, University of Khartoum, Faculty of Dentistry, Khartoum, Sudan
| | | | - Bruce R Smoller
- Department of Pathology, University of Rochester, School of Medicine and Dentistry, USA
| | - Cassian Sitaru
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104 Freiburg, Germany; BIOSS Centre for Biological Signalling Studies, Signalhaus Freiburg, Schänzlestr. 18, 79104 Freiburg, Germany.
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Abstract
PURPOSE OF REVIEW Children with rashes account for many of the outpatient visits to a general pediatrician. As such, pediatricians are often the first to identify and treat these rashes. Establishing an approach to common, uncommon and rare pediatric rashes assists in accurate assessment. This review highlights newly identified clinical patterns and disease severity. RECENT FINDINGS Group A β-hemolytic streptococci (GABHS) have been shown to be an important cause of intertrigo and to cause more widespread disease in some instances. Superficial skin infections with GABHS have been associated with strains secreting exfoliating toxins, whereas deeper infections have been associated with superantigen toxins. Hand-foot-and-mouth disease (HFMD) outbreaks have occurred with more virulent strains, causing more widespread disease that may be confused with eczema herpeticum or varicella. Mycoplasma pneumoniae has been shown to be an important cause of common disorders such as urticaria, and less common disorders such as Stevens-Johnson syndrome and Mycoplasma-associated mucositis. Recurrent toxin-mediated erythema is a recently described entity that must be differentiated from Kawasaki disease. SUMMARY The number of rashes acquired in childhood is vast, requiring the pediatrician to be able to identify worrisome rashes from those with a more benign course. Key clinical signs may assist in clinical diagnosis and treatment.
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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; 72:239-45. [PMID: 25592340 DOI: 10.1016/j.jaad.2014.06.026] [Citation(s) in RCA: 188] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 06/07/2014] [Accepted: 06/11/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Mycoplasma pneumoniae infection is associated with extrapulmonary complications, including mucocutaneous eruptions. These eruptions, which have been termed either "Stevens-Johnson syndrome" or "erythema multiforme" in the literature, may differ from drug-induced Stevens-Johnson syndrome or viral-associated erythema multiforme. OBJECTIVE We sought to review the literature characterizing morphology and disease course of M pneumoniae-associated mucocutaneous disease. METHODS A comprehensive literature search identified 95 articles with 202 cases. RESULTS Patients were often young (mean age: 11.9 years) and male (66%). Cutaneous involvement ranged from absent (34%), to sparse (47%), to moderate (19%). Oral, ocular, and urogenital mucositis was reported in 94%, 82%, and 63% of cases, respectively. Treatments included antibiotics (80%), systemic corticosteroids (35%), supportive care alone (8%), and/or intravenous immunoglobulin (8%). Complications included mucosal damage (10%), cutaneous scarring (5.6%), recurrence (8%), and mortality (3%). LIMITATIONS Mild cases may not have been published; thus this review may have a bias toward more severe disease. CONCLUSION M pneumoniae-associated mucocutaneous disease has prominent mucositis and sparse cutaneous involvement, although cutaneous involvement varies. Because of the distinct morphology, mild disease course, and potentially important clinical implications regarding treatment, we propose a revision of the nomenclature system and suggest the term "Mycoplasma-induced rash and mucositis" for these cases.
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Affiliation(s)
- Theresa N Canavan
- Department of Dermatology, University of Alabama, Birmingham, Alabama
| | - Erin F Mathes
- Department of Dermatology, University of California, San Francisco, California; Department of Pediatrics, University of California, San Francisco, California
| | - Ilona Frieden
- Department of Dermatology, University of California, San Francisco, California; Department of Pediatrics, University of California, San Francisco, California
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, California.
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Greco F, Catania R, Pira AL, Saporito M, Scalora L, Aguglia MG, Smilari P, Sorge G. Erythema Nodosum and Mycoplasma pneumoniae Infections in Childhood: Further Observations in Two Patients and a Literature Review. J Clin Med Res 2015; 7:274-7. [PMID: 25699127 PMCID: PMC4330023 DOI: 10.14740/jocmr2011w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2014] [Indexed: 11/11/2022] Open
Abstract
Erythema nodosum (EN) is the most frequent panniculitis in childhood and has been associated with various conditions, such as infectious and autoimmune disorders, medications, and malignancies. The author reports on two children affected with EN associated with Mycoplasma pneumoniae infection, which occurred in one patient without pulmonary detection. The available literature on EN and M. pneumoniae infection in childhood is also reviewed.
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Affiliation(s)
- Filippo Greco
- Unit of Clinical Pediatrics, Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - Roberta Catania
- Unit of Clinical Pediatrics, Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - Alice Le Pira
- Unit of Clinical Pediatrics, Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - Marco Saporito
- Unit of Clinical Pediatrics, Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - Luisa Scalora
- Unit of Clinical Pediatrics, Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - Maria Giovanna Aguglia
- Unit of Clinical Pediatrics, Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - Pierluigi Smilari
- Unit of Clinical Pediatrics, Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - Giovanni Sorge
- Unit of Clinical Pediatrics, Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
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32
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Prindaville B, Newell BD, Nopper AJ, Horii KA. Mycoplasma pneumonia--associated mucocutaneous disease in children: dilemmas in classification. Pediatr Dermatol 2014; 31:670-5. [PMID: 25424207 DOI: 10.1111/pde.12482] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There is controversy regarding precise definitions for Stevens-Johnson syndrome (SJS) and erythema multiforme (EM) major because of overlap in clinical presentations. SJS and EM major associated with Mycoplasma pneumoniae have been reported to occur in children, but Mycoplasma is more commonly reported with SJS. We sought to further characterize Mycoplasma-associated mucocutaneous disease. Through retrospective chart review over 10 years, six children hospitalized with a diagnosis of SJS who also tested positive for Mycoplasma infection were reviewed. Using documented physical examinations and photographs, diagnoses of SJS or EM major were retrospectively made based upon cutaneous lesional morphology employing the classification system proposed by Bastuji-Garin et al. The majority of patients were boys, with limited acral cutaneous lesions. All patients required prolonged hospitalization because of mucosal involvement and had good short-term outcomes. When the classification system was retrospectively applied, five of the six patients were reclassified with a diagnosis of EM major instead of SJS. Children with Mycoplasma-associated EM major and SJS in our small retrospective series appeared to have significant mucosal involvement but more limited cutaneous involvement with lesional morphology, which is more characteristic of EM major.
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Affiliation(s)
- Brea Prindaville
- Division of Dermatology, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
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Kavusi S, Paravar T, Hasteh F, Lee R. Atypical eruption but still Still's: case report and review of the literature. Int J Dermatol 2014; 54:e154-9. [DOI: 10.1111/ijd.12608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Suzan Kavusi
- Department of Pathology; University of California; San Diego CA USA
| | - Taraneh Paravar
- Department of Dermatology; University of California; San Diego CA USA
| | - Farnaz Hasteh
- Department of Pathology; University of California; San Diego CA USA
| | - Robert Lee
- Department of Dermatology; University of California; San Diego CA USA
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Vargas-Hitos JA, Manzano-Gamero MV, Jiménez-Alonso J. Erythema multiforme associated with Mycoplasma pneumoniae. Infection 2014; 42:797-8. [PMID: 24728737 DOI: 10.1007/s15010-014-0620-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 03/31/2014] [Indexed: 10/25/2022]
Affiliation(s)
- J A Vargas-Hitos
- Internal Medicine Department, Virgen de las Nieves University Hospital, 9th floor, Avda. Fuerzas Armadas Nº 2, 18014, Granada, Spain,
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Erythema bullous multiforme: a complication of Mycoplasma pneumoniae infection. J Pediatr 2014; 164:421. [PMID: 24252790 DOI: 10.1016/j.jpeds.2013.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 10/04/2013] [Indexed: 11/23/2022]
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Imashuku S, Kudo N. Chlamydia pneumoniae infection-associated erythema multiforme. Pediatr Rep 2013; 5:35-7. [PMID: 23904964 PMCID: PMC3718233 DOI: 10.4081/pr.2013.e9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 04/17/2013] [Indexed: 11/23/2022] Open
Abstract
There is a well-known correlation between Herpes simplex (HSV) infection and erythema multiforme (EM). More recently, in Japan, it was found that Chlamydia pneumoniae (Cp) may promote the development of EM. All cases of Cp infection-associated EM that had been diagnosed in our clinic over the past two years (from 2011 to 2012) were analyzed. Cp infection was diagnosed on the basis of a significant increase (>2.00) in anti-Cp IgM titers, as measured by the HITAZYME-ELISA test. There were 7 cases of Cp-EM, one male and 6 females. Median age was 13 years (range 3-29 years). It is recommended that the possible involvement of Cp infection, besides HSV or Mycoplasma pneumoniae infections, should be considered in all cases of EM.
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Affiliation(s)
- Shinsaku Imashuku
- Division of Pediatrics and Hematology, Takasago-seibu Hospital , Takasago, Japan
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Trapp LW, Schrantz SJ, Joseph-Griffin MA, Hageman JR, Waskow SE. A 13-year-old boy with pharyngitis, oral ulcers, and dehydration. Mycoplasma pneumoniae-associated mucositis. Pediatr Ann 2013; 42:148-50. [PMID: 23556527 DOI: 10.3928/00904481-20130326-06] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Leanne W Trapp
- Comer Children’s Hospital, Pritzker School of Medicine, University of Chicago, IL 60637, USA.
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Sargenti Neto S, de Paulo LFB, Rosa RR, Durighetto AF. Stevens-Johnson syndrome: an oral viewpoint. Int J Pediatr Otorhinolaryngol 2013; 77:284-6. [PMID: 23149180 DOI: 10.1016/j.ijporl.2012.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Revised: 10/22/2012] [Accepted: 10/22/2012] [Indexed: 10/27/2022]
Abstract
The Stevens-Johnson syndrome (SJS) is a severe variant of erythema multiforme (EM) that occasionally can rise to systemic upset and possibly compromise life. In this report, we described important oral and dermatologic aspects of a case of SJS triggered by Mycoplasma pneumoniae infection.
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Affiliation(s)
- Sergio Sargenti Neto
- Program of Specific Care of Oral Diseases, Stomatology Diagnosis Unit, Faculty of Dentistry, Federal University of Uberlândia, MG, Brazil
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Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol 2012; 51:889-902. [PMID: 22788803 DOI: 10.1111/j.1365-4632.2011.05348.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Erythema multiforme (EM) is an uncommon, immune-mediated disorder that presents with cutaneous or mucosal lesions or both. In herpes simplex virus (HSV)-associated EM, the findings are thought to result from cell-mediated immune reaction against viral antigen-positive cells that contain the HSV DNA polymerase gene (pol). The target lesion, with concentric zones of color change, represents the characteristic cutaneous finding seen in this disorder. Although EM can be induced by various factors, HSV infection continues to be the most common inciting factor. Histopathologic testing and other laboratory investigations may be used to confirm the diagnosis of EM and to differentiate it from other clinical imitators. Imitators of EM include urticaria, Stevens-Johnson syndrome, fixed drug eruption, bullous pemphigoid, paraneoplastic pemphigus, Sweet's syndrome, Rowell's syndrome, polymorphus light eruption, and cutaneous small-vessel vasculitis. Because disease severity and mucosal involvement differ among patients, treatment should be tailored to each patient, with careful consideration of treatment risk vs benefit. Mild cutaneous involvement of EM can be managed primarily with a goal of achieving symptomatic improvement; however, patients with HSV-associated recurrent EM and idiopathic recurrent EM require treatment with antiviral prophylaxis. Inpatient hospitalization may be required for patients with severe mucosal involvement that causes poor oral intake and subsequent fluid and electrolyte imbalance. With this review, we strive to provide guidance to the practicing dermatologist in the evaluation and treatment of a patient with EM.
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Affiliation(s)
- Olayemi Sokumbi
- Department of Dermatology, Mayo Clinic, Rochester, MN 55905, USA
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Shimizu M, Hamaguchi Y, Matsushita T, Sakakibara Y, Yachie A. Sequentially appearing erythema nodosum, erythema multiforme and Henoch-Schönlein purpura in a patient with Mycoplasma pneumoniae infection: a case report. J Med Case Rep 2012; 6:398. [PMID: 23176134 PMCID: PMC3520703 DOI: 10.1186/1752-1947-6-398] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 10/16/2012] [Indexed: 11/24/2022] Open
Abstract
Introduction A wide variety of skin manifestations are associated with Mycoplasma pneumoniae infection. However, the precise mechanisms by which M. pneumoniae infection is able to produce a variety of cutaneous manifestations are poorly understood. Case presentation An 8-year-old Japanese girl presented with sequential skin manifestations, including erythema nodosum, erythema multiforme and Henoch-Schönlein purpura. Although a chest radiograph showed no significant lung abnormalities, serological examinations revealed that these skin manifestations were associated with M. pneumoniae infection. Conclusion It has been reported that the variations in cutaneous manifestations of M. pneumoniae infection can be attributed to the immaturity of the adaptive immunity of a host. However, the case presented herein indicates that skin manifestations might not be specific for each individual. An awareness of the varied patterns of cutaneous disease is essential for the early diagnosis and treatment of patients with manifestations of M. pneumoniae infection.
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Affiliation(s)
- Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan.
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Hochreiter D, Jackson JM, Shetty AK. Fever, severe mucositis, and conjunctivitis in a 15-year-old male. Clin Pediatr (Phila) 2012; 51:1103-5. [PMID: 23034945 DOI: 10.1177/0009922812460915] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Meyer Sauteur PM, Goetschel P, Lautenschlager S. Mycoplasma pneumoniae and mucositis--part of the Stevens-Johnson syndrome spectrum. J Dtsch Dermatol Ges 2012; 10:740-6. [PMID: 22672205 DOI: 10.1111/j.1610-0387.2012.07951.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mycoplasma pneumoniae may induce mucosal inflammation, referred to as M. pneumoniae-associated mucositis (MPAM). There is no generally accepted definition of MPAM, since there may be mucosal lesions only, or mucosal and minimal skin lesions. PATIENTS AND METHODS We conducted a literature review of MPAM, paying particular attention to pathogenesis, clinical manifestations, treatment decisions, and prognosis. RESULTS We identified 32 cases of MPAM (median age 13.5 years), whereof 23 patients were otherwise healthy children and young adolescents (72%). M. pneumoniae infection was associated with fever and respiratory symptoms in all calls; it was confirmed by serology (n = 30) and/or PCR (n = 9). Oral lesions were present in all cases, followed by ocular (97%) and uro-genital lesions (78%). Despite the syndrome's name postulating the absence of cutaneous involvement, minimal skin lesions occurred in 31%. Treatment regimens included systemic antibiotics (100%) and systemic anti-inflammatory treatment with corticosteroids (31%) or immunoglobulins (9%). Macrolides were given in 81%, with failure, relapse, and/or worsening in one-third of patients. No patient suffered long-term sequelae. CONCLUSION MPAM is a distinct extra-pulmonary manifestation falling into the continuum of Stevens-Johnson syndrome. This entity may be due to inflammatory mechanisms suggesting that systemic anti-inflammatory treatment is even more important than antimicrobials.
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Schalock PC, Thyssen JP, Dinulos JGH. Mycoplasma pneumoniae-associated mucositis: by any other name is not so sweet. Pediatr Dermatol 2012; 29:392. [PMID: 22594340 DOI: 10.1111/j.1525-1470.2011.01694.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bressan S, Mion T, Andreola B, Bisogno G, Da Dalt L. Severe Mycoplasma pneumoniae-associated mucositis treated with immunoglobulins. Acta Paediatr 2011; 100:e238-40. [PMID: 21535132 DOI: 10.1111/j.1651-2227.2011.02342.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Mycoplasma pneumoniae-associated mucositis (MPAM), previously labelled as atypical Stevens-Johnson syndrome (SJS), SJS with minimal or no skin manifestations, is a rare non-respiratory manifestation of Mycoplasma pneumoniae infection. The nineteen cases described so far in children and young adults were characterized by a high male gender prevalence (16/19) and a good response to appropriate antibiotic treatment and supportive care in the majority of patients. We describe a case of MPAM in a previously healthy girl, who improved after a 0.5 g/kg daily dose of intravenous immunoglobulins (IVIG) for four consecutive days, after traditional therapy had failed. CONCLUSION The successful treatment with IVIG described in this report suggests that, where appropriate antibiotic and supportive therapy fails to improve the clinical course of severe MPAM, IVIG treatment is worth considering.
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Hawkins S, Rausch CM, McCanta AC. Constrictive pericarditis secondary to infection with Mycoplasma pneumoniae. Curr Opin Pediatr 2011; 23:126-9. [PMID: 21107263 DOI: 10.1097/mop.0b013e328341579c] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pericardial effusions can be insidious, variable in presentation, and may result from a wide variety of causes. We report here a rare case of pericardial effusion in a pediatric patient secondary to infection with Mycoplasma pneumoniae that progressed to cardiac tamponade and constrictive pericarditis. The differential diagnosis of pericardial effusion is reviewed as well as current treatments for pericardial effusions and constrictive pericarditis.
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Affiliation(s)
- Stephen Hawkins
- The Children's Hospital and The University of Colorado, Denver, Colorado, USA
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46
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Saint-Jean M, Tessier MH, Barbarot S, Billet J, Stalder JF. [Oral disease in children]. Ann Dermatol Venereol 2010; 137:823-37. [PMID: 21134589 DOI: 10.1016/j.annder.2010.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2010] [Indexed: 02/08/2023]
Affiliation(s)
- M Saint-Jean
- Clinique Dermatologique, CHU Hôtel-Dieu, Place A.-Ricordeau, 44093 Nantes Cedex, France
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Affiliation(s)
- Moises Auron
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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48
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Oral mucosal lesions in children from 0 to 12 years old: ten years' experience. ACTA ACUST UNITED AC 2010; 110:e13-8. [DOI: 10.1016/j.tripleo.2010.02.025] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 02/15/2010] [Accepted: 02/19/2010] [Indexed: 11/22/2022]
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Paquet P, Piérard GE. New insights in toxic epidermal necrolysis (Lyell's syndrome): clinical considerations, pathobiology and targeted treatments revisited. Drug Saf 2010; 33:189-212. [PMID: 20158284 DOI: 10.2165/11532540-000000000-00000] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Drug-induced toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a life-threatening drug reaction characterized by extensive destruction of the epidermis and mucosal epithelia. The eyes are typically involved in TEN. At present, the disease has a high mortality rate. Conceptually, TEN and the Stevens-Johnson syndrome are closely related, although their severity and outcome are different. Distinguishing TEN from severe forms of erythema multiforme relies on consideration of aetiological, clinical and histological characteristics. The current understanding of the pathomechanism of TEN suggests that keratinocytes are key initiator cells. It is probable that the combined deleterious effects on keratinocytes of both the cytokine tumour necrosis factor (TNF)-alpha and oxidative stress induce a combination of apoptotic and necrotic events. As yet, there is no evidence indicating the superiority of monotherapy with corticosteroids, ciclosporin (cyclosporine) or intravenous immunoglobulins over supportive care only for patients with TEN. However, the current theory of TEN pathogenesis supports the administration of a combination of antiapoptotic/antinecrotic drugs (e.g. anti-TNF-alpha antibodies plus N-acetylcysteine) targeting different levels of the keratinocyte failure machinery.
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Affiliation(s)
- Philippe Paquet
- Department of Dermatopathology, University Hospital of Liège, CHU Sart Tilman, Liège, Belgium.
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Duarte AF, Cruz MJ, Moreira E, Baudrier T, Mota A, Azevedo F. Stevens-Johnson syndrome/erythema multiforme major and Chlamydia pneumoniae infection in young patients. Dermatol Reports 2010; 2:e6. [PMID: 25386242 PMCID: PMC4211475 DOI: 10.4081/dr.2010.e6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Revised: 03/02/2010] [Accepted: 03/03/2010] [Indexed: 11/23/2022] Open
Abstract
Erythema multiforme major (EMM) is an acute, self-limited mucocutaneous disease characterized by the abrupt onset of symmetrical fixed red papules evolving to target lesions. It is triggered mainly by infections, such as herpes simplex virus (HSV) and Mycoplasma pneumoniae, or drugs. In instances of extensive skin lesions with “giant” targets, prominent involvement of several mucous sites and fever, it may be difficult to distinguish from Stevens-Johnson syndrome (SJS), a rarer, life-threatening reaction which is mainly drug-induced. We report a 7-year old boy with SJS and Chlamydia pneumoniae infection and 3 patients with erythema multiforme (EM) and co-infection with Chlamydia pneumoniae: a 3-year old girl and a 29-year old man developed EMM lesions associated to Mycoplasma pneumoniae and Chlamydia pneumonia and a 20-year old woman with EMM associated to herpes simplex type 2 and Chlamydia pneumoniae infection. None of the 4 patients had history of drug intake in the last two months. Chlamydia pneumoniae is an intracellular bacteria responsible for respiratory infections. Despite the fact that its role in SJS/EMM has been rarely reported, our cases suggest that it may cause SJS and trigger EM when co-infecting a patient, either with Mycoplasma pneumoniae or herpes simplex. We conclude that infection by Chlamydia pneumoniae should be suspected and ruled out in every patient with SJS/EMM, especially in those with signs of respiratory infection.
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Affiliation(s)
| | | | | | | | - Alberto Mota
- Hospital São João, EPE and Faculty of Medicine, Porto, Portugal
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