Mycoplasma pneumoniae-induced cutaneous disease

The Association between Mycoplasma pneumoniae Genotype and Cutaneous Disease

Mycoplasma pneumoniae (Mp) can cause several extrapulmonary manifestations, most frequently dermatological ones. It is largely unknown whether Mp genotype determines Mp-induced cutaneous disease. The aim of our study was to assess the association between Mp genotype and this clinical outcome. We performed a retrospective study of children referred with signs of acute Mp infection from 1 January 2014 to 31 December 2014. We compared the characteristics of children presenting as cutaneous disease, upper (URTI) and lower respiratory tract infection (LRTI). In addition, we separately analyzed the data of patients presenting with Mp-induced cutaneous disease. We evaluated data from 435 patients (mean age 7.3 years, SD 3.4 years; 52.0% boys) who had Mp PCR-positive pharyngeal swab, P1 genotype and/or multilocus variable-number tandem-repeat analysis (MLVA) genotype defined and no viral co-detection, presenting as cutaneous disease (38/435), URTI (46/435) or LRTI (351/435). The majority of patients had urticarial (55%, 21/38) or maculopapular eruptions (37%, 14/38). We found no association between Mp genotype and clinical outcome of cutaneous disease, nor any specific dermatological presentation. In the group with cutaneous disease, 18% (7/38) required hospital admission because of rash. We found that infection with MLVA-3,6,6,2 strains was more common in admitted patients than in outpatients (40% vs. 4%, p = 0.017) and significantly affected the likelihood of hospital admission in a logistic regression model. The results of our cohort study suggest that Mp genotype does not determine Mp-induced cutaneous disease or a specific dermatological presentation. Nevertheless, infections with certain MLVA strains could induce more severe cutaneous disease requiring hospitalization.

A systematic review of the clinical features of pneumonia in children aged 5-9 years: Implications for guidelines and research

Background

Childhood pneumonia presents a large global burden, though most data and guidelines focus on children less than 5 years old. Less information is available about the clinical presentation of pneumonia in children 5-9 years of age. Appropriate diagnostic and treatment algorithms may differ from those applied to younger children. This systematic literature review aimed to identify clinical features of pneumonia in children aged 5-9 years, with a focus on delineation from other age groups and comparison with existing WHO guidance for pneumonia in children less than 5 years old.

Methods

We searched MEDLINE, EMBASE and PubMed databases for publications that described clinical features of pneumonia in children 5-9 years old, from any country with no date restriction in English. The quality of included studies was evaluated using a modified Effective Public Health Project Practice (EPHPP) tool. Data relating to research context, study type, clinical features of pneumonia and comparisons with children less than 5 years old were extracted. For each clinical feature of pneumonia, we described mean percentage (95% confidence interval) of participants with this finding in terms of aetiology (all cause vs Mycoplasma pneumoniae), and method of diagnosis (radiological vs clinical).

Results

We included 15 publications, eight addressing all-cause pneumonia and seven addressing Mycoplasma pneumoniae. Cough and fever were common in children aged 5-9 years with pneumonia. Tachypnoea was documented in around half of patients. Dyspnoea/difficulty breathing and chest indrawing were present in approximately half of all-cause pneumonia cases, with no data on indrawing in the outpatient setting. Chest and abdominal pain were documented in around one third of cases of all-cause pneumonia, based on limited numbers. In addition to markers of pneumonia severity used in children <5 years, pallor has been identified as being associated with poorer outcomes alongside comorbidities and nutritional status.

Conclusions

Quality research exploring clinical features of pneumonia, treatment and outcomes in children aged 5-9 years using consistent inclusion criteria, definitions of features and age ranges are urgently needed to better inform practice and guidelines. Based on limited data fever and cough are common in this age group, but tachypnoea cannot be relied on for diagnosis. While waiting for better evidence, broader attention to features such as chest and abdominal pain, the role of chest radiographs for diagnosis in the absence of symptoms such as tachypnoea, and risk factors which may influence patient disposition (chest indrawing, pallor, nutritional status) warrant consideration by clinicians.

Protocol registration

PROSPERO: CRD42020213837.

Atypical Stevens-Johnson Syndrome Associated With Mycoplasma Pneumoniae

Mycoplasma pneumoniae primarily causes atypical pneumonia in children and young adults. 7%-8% of patients with M. pneumoniae infections may experience extra-pulmonary manifestations, including M. pneumoniae-associated Stevens-Johnson Syndrome (SJS), also known as atypical SJS. In recent literature, there have been a few reports of isolated mucositis in children with M. pneumoniae infections. Due to significant overlap with several diseases, including autoimmune disease and infections, atypical mucositis associated with M. pneumoniae is often a diagnostic challenge. In addition, due to limited cases of M. pneumoniae-associated SJS, there is no established standardized treatment guideline that has been shown to reduce hospitalization duration and/or disease progression associated with M. pneumoniae-associated SJS. We report a case of isolated mucositis in the absence of cutaneous involvement in a 10-year-old patient with an acute M. pneumoniae infection. Examination revealed erythematous ulcerations of his lips and pharynx with patchy exudates and bilateral submandibular lymphadenopathy. Laboratory investigation revealed a negative respiratory polymerase chain reaction (PCR) panel, which included M. pneumoniae. Further testing revealed a positive M. pneumoniae immunoglobulin M (IgM) titer on enzyme immunoassay. The diagnosis of atypical SJS was made secondary to M. pneumoniae. Treatment was initiated with systemic steroids and oral antibiotics. Limitations in diagnostic testing for M. pneumoniae in combination with non-specific clinical presentation make for challenges in confirming this pattern of SJS due to a primary M. pneumoniae infection. In this case, serological testing confirmed our suspected diagnosis, which guided treatment and helped reveal some of the difficulties in diagnosing and managing M. pneumoniae-associated SJS.

Case Report and Literature Review: Clinical Characteristics of 10 Children With Mycoplasma pneumoniae-Induced Rash and Mucositis

Mycoplasma pneumoniae-induced rash and mucositis (MIRM) is a rare disease, which has not been reported in northern China previously. We retrospectively analyzed the clinical characteristics, diagnosis and treatment of 10 cases of MIRM in order to help clinicians to identify MIRM and to distinguish it from the similar mucositis and cutaneous characteristics of Stevens-Johnson syndrome. All 10 children included in the study had MIRM with skin and mucosal symptoms, but the characteristics of the skin and mucosal lesions differed by age. Most of the older children had sparse erythema and a vesicular rash, but the younger children had dense erythema without blisters but with purulent exudation. The mucositis was relatively mild in the younger children. The erythrocyte sedimentation rate, the levels of C-reactive protein, lactate dehydrogenase, and D-dimer were significantly elevated in most children with MIRM. Concomitant treatment of glucocorticoids and/or IVIG with macrolides may shorten the duration of fever and accelerate the clinical recovery. Additional case reports are needed to improve knowledge of the characteristics of MIRM and its response to therapy.

Chronic Spontaneous and Inducible Urticaria Associated With Mycoplasma pneumoniae Infection

Acute childhood urticaria is a common disorder that has been associated with infections. In a few children, it may last for more than six weeks, thereafter it is characterized as chronic urticaria (CU). We report two cases, one suffering from chronic spontaneous urticaria and one chronic inducible urticarias (dermographism and cold urticaria). Both children had concomitant respiratory symptoms that were associated with Mycoplasma pneumoniae (MP) infection. Urticarias' symptoms and signs were refractory to regular antihistamines dose but showed marked improvement or complete resolution following clarithromycin administration. CU response to antibiotics pointed strongly to a potential causative role of MP in the pathogenesis of chronic spontaneous and chronic inducible urticarias. It is not clear if MP was the etiopathogenic cause or just the trigger. Nevertheless, refractory to antihistamines urticarias associated with MP infection may respond to antibiotics, which should be considered as an alternative therapeutic approach.

Mycoplasma-Induced Rash and Mucositis or Steven-Johnson Syndrome

Mycoplasma-induced rash and mucositis (MIRM), has been recently distinguished as an entity distinct from the spectrum of Steven-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). It is characterized by a younger age of onset, predominant mucosal lesions and sparse skin involvement, in contrast to widespread cutaneous lesions in TEN/SJS. While therapy with azithromycin and a short course of corticosteroids suffices in the majority of cases, intravenous immunoglobulin and cyclosporine may be useful in refractory cases. The authors report a 6-y-old girl with mucopurulent conjunctivitis, hemorrhagic oral mucosal crusting, maculopapular skin rash, and positive serology for Mycoplasma pneumoniae. The girl recovered following therapy with azithromycin and oral prednisolone. The index case is instructive in highlighting a rare complication of a common infection, and delineates the importance of clinical suspicion and a systematic approach to evaluation and management of MIRM in patients with unusual mucosal lesions and skin rash.

Mycoplasma pneumoniae Genotypes and Clinical Outcome in Children

Factors leading to the wide range of manifestations associated with Mycoplasma pneumoniae infection are unclear. We investigated whether M. pneumoniae genotypes are associated with specific clinical outcomes. We compared M. pneumoniae loads and genotypes of children with mucocutaneous disease to those of children with pneumonia, family members with upper respiratory tract infection (URTI), and carriers from a prospective cohort study (n = 47; 2016 to 2017) and to those of other children with mucocutaneous disease from a case series (n = 7; 2017 to 2020). Genotyping was performed using macrolide resistance determination, P1 subtyping, multilocus variable-number tandem-repeat analysis (MLVA), and multilocus sequence typing (MLST). Comparisons were performed with a pairwise Wilcoxon rank sum test and a Fisher exact test with corrections for multiple testing, as appropriate. M. pneumoniae loads did not statistically differ between patients with mucocutaneous disease and those with pneumonia or carriers. Macrolide resistance was detected in 1 (1.9%) patient with mucocutaneous disease. MLVA types from 2016 to 2017 included 3-5-6-2 (n = 21 [46.7%]), 3-6-6-2 (n = 2 [4.4%]), 4-5-7-2 (n = 14 [31.1%]), and 4-5-7-3 (n = 8 [17.8%]), and they correlated with P1 subtypes and MLST types. MLVA types were not associated with specific outcomes such as mucocutaneous disease, pneumonia, URTI, or carriage. They were almost identical within families but varied over geographic location. MLVA types in patients with mucocutaneous disease differed between 2016 to 2017 (3-5-6-2, n = 5 [62.5%]) and 2017 to 2020 (4-5-7-2, n = 5 [71.4%]) (P = 0.02). Our results suggest that M. pneumoniae genotypes may not determine specific clinical outcomes.

Monocyte-Independent and -Dependent Regulation of Regulatory T-Cell Development in Mycoplasma Infection

BACKGROUND

Although Mycoplasma pneumoniae (MP) infection has been implicated in the pathogenesis of allergic diseases, the mechanism of this trigger remains unknown. We explored the mechanism for how MP infection could tilt the balance between regulatory T cells (Tregs) and Th17 cells.

METHODS

We analyzed the frequency, phenotype, and function of Tregs in patients at the different stages of MP and various virus infections over a period of more than 1 year. We examined the effect of monocytes to elucidate signals that can regulate the balance between Treg and Th17 cells.

RESULTS

The functional activity of Tregs was profoundly impaired during the acute stage of MP as well as viral infections. Upon resolution, however, the Treg function remained impaired even 1 year after MP infection. In the resolution stage, the impaired Treg function was associated with an increase in interleukin (IL) 17A+ Tregs and Th17 cells. Development of Th17 cells was dependent on the "aberrant" proinflammatory monocytes (pMOs), characterized by potent ability to produce IL-6 in a Toll-like receptor 2-dependent manner.

CONCLUSIONS

Depending on the prevalence of the pMOs, Tregs and Th17 cells could mutually regulate the number and function of the other. The pMOs/IL-6 could be crucial therapeutic targets against MP-induced allergic diseases.

Frequency and Clinical Presentation of Mucocutaneous Disease Due to Mycoplasma pneumoniae Infection in Children With Community-Acquired Pneumonia

Importance

The diagnosis of Mycoplasma pneumoniae infection as the cause of mucocutaneous disease is challenging because current diagnostic tests are not able to differentiate M pneumoniae infection from carriage.

Objective

To examine the frequency and clinical presentation of M pneumoniae-induced mucocutaneous disease in children with community-acquired pneumonia (CAP) using improved diagnostics.

Design, Setting, and Participants

This prospective, longitudinal cohort study included 152 children aged 3 to 18 years with CAP enrolled in a CAP study from May 1, 2016, to April 30, 2017, at the University Children's Hospital Zurich. Children were inpatients or outpatients with clinically defined CAP according to the British Thoracic Society guidelines. Data analysis was performed from July 10, 2017, to June 29, 2018.

Main Outcomes and Measures

Frequency and clinical presentation of M pneumoniae-induced mucocutaneous disease in childhood CAP. Mycoplasma pneumoniae infection was diagnosed by polymerase chain reaction (PCR) of oropharyngeal samples and confirmed with the measurement of specific peripheral blood IgM antibody-secreting cells by enzyme-linked immunospot assay to differentiate M pneumoniae-infected patients from carriers with CAP caused by other pathogens. Mucocutaneous disease was defined as any eruptive lesion that involved skin and/or mucous membranes occurring during the CAP episode.

Results

Among 152 enrolled children with CAP (median [interquartile range] age, 5.7 [4.3-8.9] years; 84 [55.3%] male), 44 (28.9%) tested positive for M pneumoniae by PCR; of these, 10 children (22.7%) developed mucocutaneous lesions. All 10 patients with mucocutaneous eruptions tested positive for specific IgM antibody-secreting cells. Skin manifestations were found in 3 cases (2.8%) of M pneumoniae PCR-negative CAP (P < .001). The spectrum of M pneumoniae-induced mucocutaneous disease included M pneumoniae-induced rash and mucositis (3 cases [6.8%]), urticaria (2 cases [4.5%]), and maculopapular skin eruptions (5 cases [11.4%]). Two patients had ocular involvement as the sole mucosal manifestation (bilateral anterior uveitis and nonpurulent conjunctivitis). Patients with M pneumoniae-induced mucocutaneous disease had longer duration of prodromal fever (median [interquartile range], 10.5 [8.3-11.8] vs 7.0 [5.5-9.5] days; P = .02) and higher C-reactive protein levels (median [interquartile range], 31 [22-59] vs 16 [7-23] mg/L; P = .04) than patients with CAP due to M pneumoniae without mucocutaneous manifestations. They were also more likely to require oxygen (5 [50%] vs 1 [5%]; P = .007), to require hospitalization (7 [70%] vs 4 [19%]; P = .01), and to develop long-term sequelae (3 [30%] vs 0; P = .03).

Conclusions and Relevance

Mucocutaneous disease occurred significantly more frequently in children with CAP due to M pneumoniae than in children with CAP of other origins. Mycoplasma pneumoniae-induced mucocutaneous disease was associated with increased systemic inflammation, morbidity, and a higher risk of long-term sequelae.

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

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

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Associated with Mycoplasma pneumoniae Infection

Mycoplasma infection may lower the threshold for drug allergy in particular patients. We present a case of drug reaction with eosinophilia and systemic symptoms (DRESS), with drug etiology and non-drug etiology (Mycoplasma infection). Possible synergism between previously known drug allergy and the acute Mycoplasma infection may have led to DRESS eruption. Interferon-γ release test and TNF-α release test yielded different patterns in the present case, suggesting a different role for each in different drug eruption types.

A Case of Papular-purpuric “Gloves and Socks” Syndrome Caused by Mycoplasma pneumoniae

We present a case of “gloves and socks” syndrome associated with Mycoplasma pneumoniae infection in a 6-year-old child hospitalized for febrile syndrome associated with monomorphic purpuric papular eruption localized on the distal part of extremities, in a “gloves and socks” pattern. Clinical diagnosis was confirmed by positivity of specific IgM against Mycoplasma pneumoniae. Favorable outcome was obtained by administration of oral clarithromycin.

The role of mixed Mycoplasma and Herpesvirus infections in case of skin lesions in children

Numerous literature data show the role of mycoplasma infection in the development of non-respiratory lesions of various organs and systems, including the skin. Herpesvirus and mycoplasma infections can trigger the development of immune-mediated inflammatory reactions of the skin and mucous membranes — erythema multiforme exudative, Stevens-Johnson syndrome, vesicular pustular dermatosis — Sneddon-Wilkinson syndrome, etc.

In order to study the frequency and nature of skin lesions with mycoplasmosis combined with herpesvirus infection, 45 patients aged 3 to 15 years of life were observed. A comprehensive clinical and laboratory study revealed skin lesions in 27 patients associated with current mycoplasma and herpesvirus infections. Thus, multiforme exudative erythema in the small form variant was diagnosed in 13 patients, skin vasculitis in 4, hemorrhagic purpura in 3, urticaria rash in 3, erythema nodosum in 2, mucositis in 2 children. In 18 children, a combined mycoplasma and herpesvirus infection was established. In 9 children, a mono infection was detected (in 5 — herpes virus and in 4 — mycoplasma).

All observed patients showed antibodies to smooth muscle antigens in titers from 1:80 to 1:160 (normal 1:40) and in the vast majority (in 24 patients) — antibodies to vascular endothelial antigens in titers from 1:80 to 1:320 (with the norm of 1:40). Compaction of the intima-media complex was detected in 6 patients with monoinfection and in 16 patients with co-infection, according to ultrasound duplex scanning of the vessels of the brachiocephalic department.

Thus, for various immuno-inflammatory, allergic skin diseases, screening for infections, in particular, mycoplasma and herpesvirus, is necessary to optimize treatment.

Incomplete Stevens-Johnson Syndrome Caused by Sulfonamide Antimicrobial Exposure

Stevens-Johnson syndrome (SJS) is a mucocutaneous reaction typically brought on by medications or infections. The diagnosis of SJS is typically made when patients present with a variable appearing rash and involvement of the oral, ocular, or genital mucosa. However, there are rare reports of atypical or incomplete SJS. These cases are usually associated with children infected with Mycoplasma pneumoniae, which presents with severe mucositis but no rash. Herein, we report the first case of adult incomplete SJS brought on by sulfonamide antimicrobial use without clinical or laboratory evidence of M. pneumoniae infection.

Pediatric Lip Adhesion Following Bullous Erythema Multiforme and Review of Similar Oral Complications

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.

Multi-system manifestations of Mycoplasma pneumoniae infection in a young patient

Introduction.Mycoplasma pneumoniae is a small cell-wall-lacking bacterium that belongs to the mycoplasma (Mollicutes) prokaryote micro-organisms. It is a common cause of both upper and lower respiratory tract infections in all age groups. Respiratory illness is the most common manifestation of M. pneumoniae infection; however, extrapulmonary involvement may be present or predominant. The skin, mucus membranes, central nervous system, cardiovascular system, haematopoietic system, kidneys and musculoskeletal system are the most commonly involved extrapulmonary sites. Immune thrombocytopenia purpura has been reported as a rare haematological manifestation of mycoplasma infection. Here, we report, with a literature review, the case of a young adult with M. pneumoniae infection, presenting with acute febrile illness, myringitis, erythema multiforme, mild Raynaud’s phenomenon symptoms and severe thrombocytopenia.

Case presentation. Our patient was a 24-year-old healthy man who presented to an emergency department with acute febrile illness, upper respiratory tract infection symptoms, myringitis, erythema multiforme skin lesions, severe thrombocytopenia, and pale and cold hands. Mycoplasma serology suggested acute M. pneumoniae infection. The patient had a complete resolution of symptoms and gradual recovery from the thrombocytopenia after a course of anti-Mycoplasma therapy with azithromycin. Our case illustrates the multi-system involvement of M. pneumoniae infection.

Conclusion.M. pneumoniae is a frequent cause of upper and lower respiratory tract infections in children and young adults. Multi-system involvement including the skin, vascular and haematological systems in young adults with upper or lower respiratory tract infection, as in our patient, should raise the suspicion of Mycoplasma infection. Our case also illustrates an excellent clinical response and recovery from thrombocytopenia shortly after anti-Mycoplasma antimicrobial therapy.

Mycoplasma pneumoniae-induced rash and mucositis: a recently described entity

Mycoplasmapneumoniae is a common cause of respiratory infections. Although most cases are mild, some patients have extrapulmonary complications including mucocutaneous eruptions including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and erythemamultiforme (EM). Recently, a new entity, called M. pneumoniae-induced rash and mucositis (MIRM) was described. The authors present a clinical case difficult to classify attending to the classical classification of epidermolytic syndromes that meets the criteria proposed for the diagnosis of MIRM. The mucocutaneous disease associated with M. pneumoniae presents predominant mucositis, with scarce or absent cutaneous involvement. Because of the distinct morphology, pathophysiology and benign clinical course, MIRM should be considered as a new entity, distinct from SJS/TEN and EM.

Mucositis Secondary to Chlamydia pneumoniae Infection: Expanding the Mycoplasma pneumoniae-Induced Rash and Mucositis Concept

The term Mycoplasma pneumoniae-induced rash and mucositis (MIRM) was recently proposed to identify the mucocutaneous condition secondary to M. pneumoniae infection that had historically been regarded among the more confusing pathologies of erythema multiforme and Stevens-Johnson syndrome. Based on a number of previous reports, these syndromes require differentiation since they have different prognoses and specific treatment requirements. We report a case of oral and genital erosions that strongly resembled MIRM without rash but were found to be secondary to a Chlamydia pneumoniae infection. After a thorough review of the literature on this subject, we propose that C. pneumoniae should also be considered a potential causative agent of MIRM and that this term should be amended to include C. pneumoniae infection.

A case of urticarial vasculitis in a female patient with lupus: Mycoplasma pneumoniae infection or lupus reactivation?

A 17-year-old female patient affected by systemic lupus erythematosus (SLE) (who had been taking 300 mg/die of hydroxychloroquine for 3 years), Graves' disease (treated with 10 mg/die of tapazole), and celiac disease came to our attention for urticarial vasculitis. She had been taking prednisone (25 mg/die) for 3 days, and her blood tests showed high levels of Mycoplasma pneumoniae IgM and IgG antibodies. The association between urticaria and M. pneumoniae infections can be present in up to 7% of the cases and, to the best of our knowledge, only two reports of urticarial vasculitis and M. pneumoniae in adults are available in the literature. Urticarial vasculitis can also be a rare cutaneous manifestation of SLE (affecting 2% of the patients), and our case is the first in the literature describing the coexistence of M. pneumoniae infection, SLE, and urticarial vasculitis in a pediatric patient, a case that rises an important differential diagnosis issue about the origin of urticarial vasculitis: SLE reactivation or urticarial vasculitis due to M. pneumoniae infection?

Infection with and Carriage of Mycoplasma pneumoniae in Children

“Atypical” pneumonia was described as a distinct and mild form of community-acquired pneumonia (CAP) already before Mycoplasma pneumoniae had been discovered and recognized as its cause. M. pneumoniae is detected in CAP patients most frequently among school-aged children from 5 to 15 years of age, with a decline after adolescence and tapering off in adulthood. Detection rates by polymerase chain reaction (PCR) or serology in children with CAP admitted to the hospital amount 4–39%. Although the infection is generally mild and self-limiting, patients of every age can develop severe or extrapulmonary disease. Recent studies indicate that high rates of healthy children carry M. pneumoniae in the upper respiratory tract and that current diagnostic PCR or serology cannot discriminate between M. pneumoniae infection and carriage. Further, symptoms and radiologic features are not specific for M. pneumoniae infection. Thus, patients may be unnecessarily treated with antimicrobials against M. pneumoniae. Macrolides are the first-line antibiotics for this entity in children younger than 8 years of age. Overall macrolides are extensively used worldwide, and this has led to the emergence of macrolide-resistant M. pneumoniae, which may be associated with severe clinical features and more extrapulmonary complications. This review focuses on the characteristics of M. pneumoniae infections in children, and exemplifies that simple clinical decision rules may help identifying children at high risk for CAP due to M. pneumoniae. This may aid physicians in prescribing appropriate first-line antibiotics, since current diagnostic tests for M. pneumoniae infection are not reliably predictive.

Rare extrapulmonary complications of Mycoplasma pneumoniae infection

Stevens-Johnsons syndrome (SJS) is a rare extra-pulmonary complication of Mycoplasma pneumoniae infection. We present the case of a 26-year-old man with fever, cough, extensive oral mucosal ulceration and a widespread truncal rash. He was diagnosed with M. pneumoniae-induced SJS. He responded well to antibiotics and steroids initially, but went on to develop pseudomembranous conjunctivitis requiring bilateral amniotic membrane grafting. SJS is most commonly drug-induced, however, M. pneumoniae is the commonest infectious cause and should be considered in the differential diagnosis. It is also important to get specialist care involved early to minimise the long-term effects of any complications.

Classification of Extrapulmonary Manifestations Due to Mycoplasma pneumoniae Infection on the Basis of Possible Pathogenesis

The list of extrapulmonary manifestations due to Mycoplasma pneumoniae infection can be classified according to the following three possible mechanisms derived from the established biological activity of M. pneumoniae; (1) a direct type in which the bacterium is present at the site of inflammation and local inflammatory cytokines induced by the bacterium play an important role (2) an indirect type in which the bacterium is not present at the site of inflammation and immune modulations, such as autoimmunity or formation of immune complexes, play an important role, and (3) a vascular occlusion type in which obstruction of blood flow induced either directly or indirectly by the bacterium plays an important role. Recent studies concerning extrapulmonary manifestations have prompted the author to upgrade the list, including cardiac and aortic thrombi as cardiovascular manifestations; erythema nodosum, cutaneous leukocytoclastic vasculitis, and subcorneal pustular dermatosis as dermatological manifestations; acute cerebellar ataxia, opsoclonus-myoclonus syndrome, and thalamic necrosis as neurological manifestations; pulmonary embolism as a respiratory system manifestation; and renal artery embolism as a urogenital tract manifestation. Continuing nosological confusion on M. pneumoniae–induced mucositis (without skin lesions), which may be called M. pneumoniae-associated mucositis or M. pneumoniae-induced rash and mucositis separately from Stevens-Johnson syndrome, is argued in the dermatological manifestations. Serological methods are recommended for diagnosis because pneumonia or respiratory symptoms are often minimal or even absent in extrapulmonary manifestations due to M. pneumoniae infection. Concomitant use of immunomodulators, such as corticosteroids or immunoglobulins with antibiotics effective against M. pneumoniae, can be considered as treatment modalities for most severe cases, such as encephalitis. Further studies would be necessary to construct a comprehensive therapeutic strategy, covering microbiology (antibiotics), immunology (immunomodulators), and hematology (anticoagulants). The possible influence of the emergence of macrolide-resistant M. pneumoniae on extrapulmonary manifestations, which can be considered of limited clinical threat in Japan where the resistant rate has currently decreased, is discussed on the basis of unique biological characteristics of M. pneumoniae, the smallest self-replicating organism.

Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review

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.

Erythema Nodosum and Mycoplasma pneumoniae Infections in Childhood: Further Observations in Two Patients and a Literature Review

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.

Mycoplasma pneumonia-associated mucositis

We present a case of a young man with severe mucositis following an upper respiratory tract infection limited to the ophthalmic and oral mucosa while sparing the rest of the skin, genitalia and perianal regions. Investigations revealed that the mucositis was a rare extrapulmonary manifestation of Mycoplasma pneumoniae infection. He had progressive vision-threatening symptoms despite antibiotics and best supportive care and thus was treated with intravenous corticosteroids, immunoglobulins, temporary ocular amniotic membrane grafts and tarsorrhaphy. The patient made an almost complete recovery over 6 weeks.

Mycoplasma pneumoniae with atypical stevens-johnson syndrome: a diagnostic challenge

The Stevens-Johnson syndrome (SJS) classically involves a targetoid skin rash and the association of the oral mucosa, genitals, and conjunctivae. Recently, there have been several documentations of an incomplete presentation of this syndrome, without the typical rash, usually associated with the mycoplasma pneumoniae infection. Our case illustrates that this important clinical diagnosis should not be missed due to its atypical presentation.

Sequentially appearing erythema nodosum, erythema multiforme and Henoch-Schönlein purpura in a patient with Mycoplasma pneumoniae infection: a case report

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.

Mycoplasma pneumoniae-Induced-Stevens Johnson Syndrome: Rare Occurrence in an Adult Patient

Stevens-Johnson syndrome (SJS) is an uncommon occurrence in Mycoplasma pneumoniae (M. pneumoniae) infection (1–5%) and has been mainly reported in children and young adults. We present a case of SJS in a 32-year-old male induced by M. pneumoniae infection. This patient presented with fever, cough, and massive occupation of mucus membranes with swelling, erythema, and necrosis accompanied by a generalized cutaneous rash. He clinically responded after treatment with antibiotics and IVIG. SJS is usually a drug-induced condition; however, M. pneumoniae is the commonest infectious cause and should be considered in the differential diagnosis.

Mycoplasma pneumoniae and mucositis--part of the Stevens-Johnson syndrome spectrum

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.

Eosinophilic Fasciitis associated with Mycoplasma arginini infection

Eosinophilic fasciitis (EF) with generalized sclerodermiform skin lesions developed over a 19-month period in a previously healthy 23-year-old man. Although we confirmed EF by skin histology and laboratory tests, the recurrent fevers and the clinical observation of sclerotic prepuce with urethritis indicated further bacteriological analysis by conventional microbiological and DNA-based tests. Urethra cultures were positive for an arginine-hydrolyzing mycoplasma and Ureaplasma urealyticum. The patient also had serum IgM antibodies to Mycoplasma pneumoniae using enzyme-linked immunosorbent assay (ELISA)-based qualitative detection. Mycoplasma arginini was isolated from two independent venous blood serum samples and was identified by conventional microbiological tests and sequencing of the 16S rRNA and rpoB genes (GenBank sequence accession numbers HM179555 and HM179556, respectively). M. arginini genomic DNA also was detected by species-specific PCR in the skin lesion biopsy sample. Treatment with corticosteroids and long-term courses of selected antibiotics led to remission of skin symptoms and normalization of laboratory values. This report provides the first evidence of EF associated with mycoplasma infection and the second report of human infection with M. arginini and therefore suggests that this mycoplasma infection might have contributed to the pathogenesis of the disease.

Mycoplasma pneumoniae infection presenting as bullous papular purpuric gloves and socks syndrome: novel association and review of the literature

Papular purpuric gloves and socks syndrome (PPGSS) is a self-limited, often febrile illness with symmetric edema and erythema of the hands and feet; papular, petechial, and purpuric acral dermatosis; and mucosal lesions in children and young adults. Most of the cases of PPGSS have been reported to be caused by parvovirus B19 and other viruses. This study describes a case resulting from Mycoplasma pneumoniae infection in an adolescent male and reviews the literature.

Severe Mycoplasma pneumoniae-associated mucositis treated with immunoglobulins

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.