Erythema Multiforme Major Associated With Community-Acquired Pneumonia: Lessons From a Case Report

Abstract

Background: Erythema multiforme (EM) is an acute immune-mediated inflammatory mucinous skin disorder. The etiology of pediatric EM involves infections, medications, autoimmune diseases, and genetic factors.Case Report: An 8-year-old girl with Mycoplasma pneumoniae (MP) associated community-acquired pneumonia developed erythema target-like symptoms 1 week after azithromycin administration. The erythema quickly spread throughout the body involving the oral and ocular mucous membranes, the trunk, and the extremities, and eventually developed into erythema multiform major (EMM). Through drug withdrawal and specific treatment including systemic corticosteroids and supportive care, her clinical symptoms were improved. After 31 days, most of the mucocutaneous symptoms were relieved, except pigmentation. Human leukocyte antigen (HLA) gene sequencing was performed and 20 HLA genotypes were identified. The patient follow-up lasted for 18 months. Rashes appeared on her trunk when receiving azithromycin orally after discharge and then disappeared after azithromycin withdrawal.Conclusions: Pediatric EM is a rare disease and recognition of its etiology is important for EM management. In this case, azithromycin and HLA-DQB1*03:01 genotype may contribute to EMM.Lesson: For drug-induced EM, rapid identification and withdrawal of the causative drugs is critical. Re-exposure to the same drug or exposure to drugs with similar chemical structures should also be avoided. Patient education and rational use of medicines are essential for pediatric patients.

The Association between Mycoplasma pneumoniae Genotype and Cutaneous Disease

“…Cutaneous disease is the most common extrapulmonary presentation of Mp infection [ 1 , 5 , 6 , 7 , 8 , 9 , 10 ]. The factors determining disease presentation and severity of Mp -induced cutaneous disease are only partly understood, with undiscovered roles for both pathogen- and host-related factors.…”

“…The most prevalent form of extrapulmonary manifestations are the dermatological ones. It is estimated that up to one-third of patients with Mp infection have some cutaneous form of disease [ 5 , 6 , 7 , 8 , 9 , 10 ].…”

Typical target lesion with a central blister in erythema multiforme major caused by drug allergy in a toddler

“…The presence of a target acral lesion, sometimes with the involvement of the body and blisters in the center of the target lesion involving less than 10% of the body surface area, and the presence of two or more mucosal involvements (eyes, mouth, and/or genitals) are used to determine EMM (11,20,21) . In EM, prodromal signs are uncommon; moderate symptoms such as cough, rhinitis, and low-grade fever are more common.…”

Oral erythema multiforme related to bronchodilators intake: A report of a case

“…5,9,10 For the etiology, erythema multiforme is usually related to an immunological reaction to bacterial (mycoplasma pneumonia, mycobacteria, brucellosis), viral (herpes simplex, AIDS, adenovirus, enterovirus), or fungal infections (coccidioidomycosis, dermatophytosis, histoplasmosis) infections, radiation therapy, malignancies, emotional stress, and drugs.as it was the case for our patient. 3,4,11,12 The most common drugs incriminated are as follows: sulfonamides, nonsteroidal anti-inflammatory drugs, carbamazepine, vancomycin, phenytoin, co-trimoxazole; barbituric…. 9,10,13,14 Also, some bronchodilators and antiasthmatics can induce erythema multiforme as it was in our case in which we have the association between the bronchial asthma drug intake and incidence of lesions.…”