Oral and Penile Lesions in a Young Man

Abstract

A 28-year-old man presented to the emergency department with diffuse oral lesions, fever, and nonproductive cough for 1 week. He was diagnosed with herpes simplex virus (HSV) and discharged home with acyclovir. Two days later, he returned with worsening oral lesions, painful phonation, poor oral intake, odynophagia, and new painful penile lesions. He denied any abdominal pain, diarrhea, rectal bleeding, weight loss, arthralgia, fatigue, vision changes, or skin rashes. He reported a similar episode of widespread oral lesions 18 months earlier that was less severe and self-resolving. He had no other medical conditions, took no medications, and was sexually monogamous with his wife, who was asymptomatic.The patient was hemodynamically stable and had a normal respiratory examination. He had a fever (39.4°C) on presentation, but his temperature abated overnight and he remained afebrile for the rest of the admission. His superior and inferior lips had extensive well-circumscribed erosions and ulcerations with erythematous edges, crusting, and a gray-white base (Figure, left). Lesions extended into the buccal mucosa and soft palate. His tongue was enlarged with fissures. A genital examination showed similar lesions on the penis, with scalloped borders (Figure , right). There were no skin lesions, lymphadenopathy, or hepatosplenomegaly.Results of laboratory tests from the emergency department were normal, and a chest radiograph showed no evidence of pneumonia. Results of further testing for antinuclear antibodies, erythrocyte sedimentation rate, C-reactive protein level, HIV, HSV serology, syphilis, chlamydia, and gonorrhea were negative. Bacterial and viral cultures of the oral and penile lesions were also negative. Serum enzyme immunoassay for Mycoplasma pneumoniae IgM was positive at 1280 U/mL. The patient did not consent to a punch biopsy of the oral lesions. Diagnosis M pneumoniae-induced rash and mucositis (MIRM) What to Do Next C. Prescribe oral azithromycinThe key to the correct diagnosis is the elevated M pneumoniae IgM titers in a patient with a nonproductive cough and 2 sites of mucosal lesions. Although Crohn disease and systemic lupus erythematosus can present with oral lesions, the patient's lack of associated gastrointestinal or musculoskeletal symptoms make these Figure. Left, Extensive well-circumscribed oral lesions limited to the mucosa in a 28-year-old man. Right, Similar lesions with scalloped borders on the distal shaft and glans of the penis in the same patient. WHAT WOULD YOU DO NEXT? A. Perform upper endoscopy and colonoscopy B. Test for anti-double-stranded DNA antibodies C. Prescribe oral azithromycin D. Prescribe oral suspension nystatin Clinical Review & Education