Mycoplasma pneumoniae incidence, phenotype, and severity in children and adolescents in Denmark before, during, and after the COVID-19 pandemic: a nationwide multicentre population-based cohort study

Background

Mycoplasma pneumoniae infections resurged globally in 2023-2024 after a three-year decline during the COVID-19 pandemic. We explored the incidence and severity of M pneumoniae infections in children and adolescents before, during, and after the pandemic.

Methods

This nationwide, population-based cohort study included all Danish children and adolescents aged 0-17 years with a positive M pneumoniae PCR test from May 1, 2016, to April 30, 2024. We obtained clinical details for patients hospitalised for 24 h or more. Risk ratios for infections, hospitalisations, and disease manifestations in 2023-2024 versus pre-COVID-19 seasons were calculated using Fisher's exact and Pearson's χ2 tests. A season was defined from May 1 to April 30.

Findings

Among the Danish population of 1,152,000 children and adolescents, 14,241 with a positive PCR test for M pneumoniae were included. In 2023-2024, children and adolescents with a positive PCR rose 2.9-fold (95% CI 2.8-3.1; p < 0.0001) compared to the pre-COVID-19 seasons, and hospitalisations rose 2.6-fold (95% CI 2.0-3.3; p < 0.0001). M pneumoniae-induced rash and mucositis increased 5.3-fold (95% CI 1.8-15.3; p = 0.0007). In 2023-2024 compared to the pre-COVID-19 seasons, there was no difference in the proportion of hospitalisation (360 [4%] of 8165 versus 230 [4%] of 6009; p = 0.09), the median duration of hospital stay (3 days [IQR 2-5] versus 3 days [IQR 2-5]; p = 0.84), or paediatric intensive care unit admission (14 [4%] of 360 versus 9 [4%] of 230 p = 1.00).

Interpretation

In Denmark, M pneumoniae infections and hospitalisations increased three-fold in 2023-2024 compared with the pre-COVID-19 seasons, indicating an immunity debt caused by the decline in M pneumoniae during the COVID-19 pandemic. While the severity of M pneumoniae infections did not change in 2023-2024, the five-fold increase in M pneumoniae-induced rash and mucositis in children and adolescents highlights M pneumoniae as an important pathogen causing mucocutaneous eruptions.

Funding

Innovation Fund Denmark and Rigshospitalets Forskningsfond.

A severe case of reactive infectious mucocutaneous eruption associated with two possible triggers: Coronavirus and group A streptococcus

Reactive infectious mucocutaneous eruption (RIME) is a newly defined condition characterized by mucocutaneous blistering secondary to upper respiratory infections and encompasses Mycoplasma pneumoniae-induced rash and mucositis, broadening the disease spectrum to include various infectious etiologies. We present a severe RIME case involving a 5-year-old female with concurrent coronavirus NL63 and group A streptococcus infections. Diagnosis complexity stemmed from overlapping clinical features with other severe mucocutaneous eruptions such as Stevens-Johnson syndrome/toxic epidermal necrolysis/drug-induced necrolysis. This case underscores the need for comprehensive infectious workup and emphasizes the clinical diagnostic spectrum of drug-induced and infection-induced desquamative skin and mucosal disease.

Evolving trends in inpatient paediatric dermatology

PURPOSE OF REVIEW

This review provides updates in the evaluation and management of key dermatologic diseases encountered in the hospitalized child.

RECENT FINDINGS

Our understanding of dermatologic disorders in children continues to evolve. Staphylococcal scalded skin syndrome (SSSS) is a potentially severe blistering disorder typically seen in children under the age of 4 with an incidence that is increasing in the United States. Recent research has highlighted that the majority of cases are due to methicillin-sensitive Staphylococcus aureus (MSSA) and most patients can be adequately managed with beta-lactams. Toxic epidermal necrolysis (TEN) is one of the most feared dermatologic disorders. Currently, there is a lack of consensus on the most efficacious first-line systemic therapy. Etanercept is increasingly being used based on studies showing a shorter time to re-epithelization and decreased mortality. Lastly, the COVID-19 pandemic introduced the novel inflammatory condition multisystem inflammatory syndrome in children (MIS-C) in which approximately three out of four children present with a mucocutaneous eruption. Early recognition of the dermatologic features of MIS-C is important in potentially establishing a diagnosis and differentiating it from the many other causes of childhood fever and rash.

SUMMARY

There are no clear universal treatment guidelines for these rare diagnoses, and therefore, clinicians must remain informed of the latest findings in diagnosis and therapeutics.

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.

Reactive infectious mucocutaneous eruption following COVID-19 in an adolescent boy: Case report and review of the literature

Reactive infectious mucocutaneous eruption (RIME) is a mucosal-predominant eruption that usually affects two or more mucosal sites. We present a case of RIME secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and provide a brief review of the literature with a focus on the natural history and response to treatment. This entity may require inpatient management and systemic corticosteroids for symptom control in the pediatric population.

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

A 6-year-old boy taking no regular medications had persistent fever and cough for 15 days. Physical examination revealed eyelid swelling; vesiculobullous lesions on the palms and soles; vesicles and erosions on the face, trunk, and limbs; erosions on the lips and oral mucosa; and blisters on the anal mucosa. Laboratory testing revealed leukocytosis, and lung auscultation revealed bilateral crackles. What is the diagnosis and what would you do next?

The impact of HMG-CoA reductase inhibitors use on the clinical outcomes in critically ill patients with COVID-19: A multicenter, cohort study

Background

The cardiovascular complications of Coronavirus Disease 2019 (COVID-19) may be attributed to the hyperinflammatory state leading to increased mortality in patients with COVID-19. HMG-CoA Reductase Inhibitors (statins) are known to have pleiotropic and anti-inflammatory effects and may have antiviral activity along with their cholesterol-lowering activity. Thus, statin therapy is potentially a potent adjuvant therapy in COVID-19 infection. This study investigated the impact of statin use on the clinical outcome of critically ill patients with COVID-19.

Methods

A multicenter, retrospective cohort study of all adult critically ill patients with confirmed COVID-19 who were admitted to Intensive Care Units (ICUs) between March 1, 2020, and March 31, 2021. Eligible patients were classified into two groups based on the statin use during ICU stay and were matched with a propensity score based on patient's age and admission APACHE II and SOFA scores. The primary endpoint was in-hospital mortality, while 30 day mortality, ventilator-free days (VFDs) at 30 days, and ICU complications were secondary endpoints.

Results

A total of 1,049 patients were eligible; 502 patients were included after propensity score matching (1:1 ratio). The in-hospital mortality [hazard ratio 0.69 (95% CI 0.54, 0.89), P = 0.004] and 30-day mortality [hazard ratio 0.75 (95% CI 0.58, 0.98), P = 0.03] were significantly lower in patients who received statin therapy on multivariable cox proportional hazards regression analysis. Moreover, patients who received statin therapy had lower odds of hospital-acquired pneumonia [OR 0.48 (95% CI 0.32, 0.69), P < 0.001], lower levels of inflammatory markers on follow-up, and no increased risk of liver injury.

Conclusion

The use of statin therapy during ICU stay in critically ill patients with COVID-19 may have a beneficial role and survival benefit with a good safety profile.

Stevens-Johnson syndrome in children

PURPOSE OF REVIEW

The concept of Stevens-Johnson syndrome (SJS) in children is evolving. This manuscript reviews recent advances with the lens of new terminology namely infection-triggered reactive infectious mucocutaneous eruption and drug-induced epidermal necrolysis, with the objective of integrating this novel terminology practically.

RECENT FINDINGS

Traditionally considered to exist on a spectrum with toxic epidermal necrolysis, SJS in children is more often caused or triggered by infections instead of medications. Proposed pediatric-specific terminology can be applied to literature to gain further insights into blistering severe cutaneous adverse reactions.

SUMMARY

Distinguishing infection-triggered from drug-triggered blistering reactions is useful for 3 main reasons: (1) early clinically recognizable different features such as isolated or predominant mucositis, (2) different initial management depending on trigger, (3) avoiding the label of a drug reaction on cases triggered by infection.

Reactive infectious mucocutaneous eruption – repeat etanercept after intravenous immunoglobulin: A case report

Reactive infectious mucocutaneous eruption is a recently distinguished mucosal-predominant blistering eruption triggered by respiratory infections. We describe a previously healthy 11-year-old Black female with rapidly progressive mucocutaneous blistering after prodromal respiratory infection symptoms. Reactive infectious mucocutaneous eruption was suspected and treated with systemic corticosteroids followed by etanercept. Twenty-four hours after etanercept, the diagnosis of multisystem inflammatory syndrome in children was raised and intravenous immunoglobulin was given. Rapidly worsening mucocutaneous disease ensued but was controlled by a second dose of etanercept. Our case highlights the following: (1) the novel observation of possible interaction/neutralization of etanercept by intravenous immunoglobulin, (2) the challenging differential diagnosis of multisystem inflammatory syndrome in children for reactive infectious mucocutaneous eruption patients in the Coronavirus disease 2019 (COVID-19) pandemic, and (3) the role of early treatment to prevent dyspigmentation.

Post-covid syndrome in children

Multisystem inflammatory syndrome in children associated with COVID-19 is a new disease, information first appeared in April 2020. There were reported cases of hospitalized children with unusual symptoms, manifested primarily by fever and multisystem inflammation from the pediatricians in the UK and other countries during the coronavirus infection pandemic (COVID-19). Some of these children were in critical condition with symptoms of shock and multiple organ failure, and some children had manifestations similar to Kawasaki disease. Despite the fact that COVID-19 in children is relatively easy, some of the «convalescents» after 2–6 weeks develop symptoms largely identical to the manifestations of severe forms of new coronavirus infection in adults. The report presents own clinical cases of multisystem inflammatory syndrome that developed in children after acute form of a new coronavirus infection. The authors discuss the possible clinical variants of the syndrome, its origin and outcomes.

Stevens-Johnson syndrome associated with Hodgkin's lymphoma

Hodgkin's lymphoma accounts for approximately 40% of all lymphomas presenting in childhood and can be associated with a variety of dermatologic manifestations. Here, we describe a case of Hodgkin's lymphoma presenting with Stevens-Johnson syndrome. Clinicians should be aware of this association, especially if no alterative trigger for Stevens-Johnson syndrome can be identified.

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.

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.

Mycoplasma pneumoniae-associated mucositis complicated by herpes simplex virus dissemination and Staphylococcus Epidermidis bacteremia

Prominent mucositis with minimal or no cutaneous involvement in the setting of Mycoplasma pneumoniae infection describes a clinical entity recently termed Mycoplasma-induced rash and mucositis (MIRM). About 81% of patients with MIRM experience complete resolution; however, the disease course in approximately 11% of patients is complicated by mucosal sequelae. We describe a patient with MIRM complicated by HSV dissemination and Staphylococcus epidermidis bacteremia and outline the management of mucocutaneous eruptions without systemic immunosuppressant agents.

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.