Outbreak of Mycoplasma pneumoniae–Associated Stevens-Johnson Syndrome

Abstract

BACKGROUND: Stevens-Johnson syndrome (SJS) is an uncommon, sporadic disease and outbreaks are rare. In November 2013, an outbreak of SJS was identified at Children's Hospital Colorado.METHODS: Outbreak cases were children aged 5-21 with a discharge diagnosis of SJS admitted from September 1 to November 30, 2013. Medical charts were reviewed using standardized data collection forms. Respiratory specimens were tested for viruses and Mycoplasma pneumoniae (Mp) by polymerase chain reaction (PCR). We conducted a separate 4-year retrospective case-control study comparing hospitalized SJS cases with and without evidence of Mp infection.RESULTS: During the outbreak, 8 children met SJS criteria. Median age was 11.5 years (range 8-16 years); 5 (63%) were boys and 5 (63%) were Mp-PCR-positive. Of the 5 PCR-positive children, none had preceding medication exposure, and all had radiographic pneumonia. All outbreak Mp isolates were macrolide susceptible. The retrospective case-control analysis showed that Mp-associated SJS episodes (n = 17) were more likely to have pneumonia (odds ratio [OR] 10.0, confidence interval [CI] 1.3-5.1), preceding respiratory symptoms (OR 30.0, CI 1.6-72.6), an erythrocyte sedimentation rate $35 mg/dL (OR 22.8, CI 2.1-244.9), and #3 affected skin sites (OR 4.5, CI 1.2-17.4) than non-Mp-associated SJS episodes (n = 23). CONCLUSIONS:We report the largest outbreak of SJS in children, which was also predominately associated with Mp infection. Mp-associated SJS was associated with a distinct clinical presentation that included less extensive skin disease, an elevated erythrocyte sedimentation rate, and evidence of a preceding respiratory infection.WHAT'S KNOWN ON THIS SUBJECT: StevensJohnson syndrome (SJS) is a rare and severe immunologic phenomenon characterized by rash and mucous membrane disease. SJS may be triggered by medications and, less commonly, by infections such as Mycoplasma pneumoniae (Mp). Outbreaks of SJS are exceedingly rare. WHAT THIS STUDY ADDS:We describe the largest SJS outbreak reported in children, which was also Mp-associated. In the first case-control study of this disease, we identify predictors of Mp-associated SJS versus non-Mp-associated SJS, including fewer skin lesions, pneumonia, and elevated erythrocyte sedimentation rate.

Epidemiology and Molecular Characteristics of Mycoplasma pneumoniae During an Outbreak of M. pneumoniae-associated Stevens-Johnson Syndrome

“…In the 5 years prior to September 1, 2013, CHCO treated an average of 7.5 children with SJS per year, of whom 32% had confirmed or probable M. pneumoniae infection on chart review. 17 Therefore, the 8 cases that occurred between September 1 and November 30, 2013 represented a significant rise above the expected number of cases by cumulative sum analysis, 17 prompting further investigation into the possible reasons for this increase.…”

“…17 We surveyed household contacts, defined as any person living in the same residential unit as an SJS case-patient with confirmed M. pneumoniae infection, for each of these 3 case-patients. Consenting adults and assenting children were interviewed about the presence and timing of respiratory or skin symptoms as well as any clinic visits, hospitalizations, diagnoses of pneumonia or medication use over the preceding 2 months.…”

“…An investigation into this cluster of cases revealed that of the 8 SJS case-patients (8–16 years of age) identified between September 1 and November 30, 2013, 5 had confirmed [ M. pneumoniae polymerase chain reaction (PCR) positive] and 3 had possible (concurrent radiographic pneumonia or fever plus cough, shortness of breath or hypoxia) infection with M. pneumoniae , making this one of the largest reported outbreaks of M. pneumoniae -associated SJS to date. 17 …”

Detection of macrolide resistant Mycoplasma pneumoniae in England, September 2014 to September 2015

“…M. pneumoniae infections may manifest infrequently as extra-pulmonary sequelae after the onset of or even in the absence of respiratory illness [5]; including encephalitis [6], dermatological manifestations such as Stevens-Johnson syndrome [7], and haemolytic anaemia [8]. Asymptomatic carriage of M. pneumoniae has been documented in nasopharyngeal swabs at low levels in England, e.g.…”

Severe Delayed Drug Reactions

“…One of these cases had a concurrent pneumonia, a presentation that is consistent with what is now known as Mycoplasma-pneumoniae -induced rash and mucositis (MIRM). 38,39 Studies have reported that 14–63% of children with clinical SJS/TEN have detectable M. pneumoniae serum antibodies 40,41 and M. pneumoniae is recognized as a major trigger for re-current SJS episodes, particularly in children and adolescents. 40,42 SJS/TEN with eye involvement is more common in children with concurrent M. pneumoniae (26.7%) or HSV (15.6%) infections.…”