Toxic Epidermal Necrolysis From SuspectedMycoplasma pneumoniaeInfection

Abstract

Introduction: Toxic Epidermal Necrolysis (TEN) is primarily associated with medication use. Presented is a patient with likely Mycoplasma pneumoniae infection and progression to TEN. Case: A 19-year-old male presented with 1-week history of pneumonia like symptoms and prescribed antibiotics for suspected community-acquired pneumonia. Onset of a new rash was noted and antibiotics were discontinued less than 24 hours after initiation. The diffuse, maculopapular, bullous rash with mucosal lesions ultimately reached skin involvement greater than 30%. Histological studies were consistent with TEN. Mycoplasma antibodies and cold agglutinins were positive. Discussion: Stevens-Johnson syndrome (SJS) and TEN are a spectrum of mucocutaneous disorders. The most common etiology of both is medications. Mycoplasma is the most common infectious cause of SJS, but has been poorly cited as a cause of TEN. Typical onset of rash from medications is greater than 14 days, whereas onset from infection is typically less than 14 days. The timing of rash onset in this presentation was congruent with infection rather than medication induced. Conclusion: Mycoplasma is a welldocumented etiology of SJS, but rarely documented as an etiology of TEN. This case suggests the potential of Mycoplasma infection causing more severe mucocutaneous disease in the spectrum of SJS and TEN. INTRODUCTIONToxic epidermal necrolysis (TEN) is a potentially lethal mucocutaneous process with mortality greater than 20%.1 Debate remains on pathogenesis of TEN and Stevens-Johnson syndrome (SJS) regarding whether the diagnoses are part of a spectrum. However, there is an agreement that body surface area (BSA) involvement defines the processes, with TEN involving greater than 30% BSA and SJS involving less than 10% BSA. The most common etiology of TEN is medication use, which is implicated in greater than 95% of cases.

Insights into the pathogenesis of Mycoplasma pneumoniae

“…M. pneumoniae also exerts its toxin-like effects through its metabolites, exotoxin and exotoxin-like toxic substances, lipids, lipopolysaccharides and membrane lipoprotein (28). Following the adherence of M. pneumoniae onto the surface of bronchial cells, with the cytoskeleton rearrangement, M. pneumoniae penetrates through the bronchial mucous membranes and releases nuclease and H2O2, which result in swelling, necrosis and a binding of bronchial epithelial cells, slower microvilli movement, structural deformation, and the termination of swinging, thereby inducing the infiltration of lymphocytes, plasma cells and monocytes (22,29).…”

A retrospective analysis of Stevens–Johnson syndrome/toxic epidermal necrolysis treated with corticosteroids

“…Stevens–Johnson syndrome and TEN are mainly believed to be caused by a drug hypersensitivity reaction, and microbial infection is occasionally indicated as a cause of disease . The basic treatment includes discontinuing the culprit drug, giving fluids, providing nutritional support, maintaining the water and electrolyte balance, and handling skin and mucous membrane peeling with care .…”

“…Stevens-Johnson syndrome and TEN are mainly believed to be caused by a drug hypersensitivity reaction, 9,10 and microbial infection is occasionally indicated as a cause of disease. 1 The basic treatment includes discontinuing the culprit drug, giving fluids, providing nutritional support, maintaining the water and electrolyte balance, and handling skin and mucous membrane peeling with care. 11 Our study revealed there to be a high rate of suspected infection before the onset of SJS/TEN (40.7% and 50.0% in the low-and high-dose groups, respectively), and the proportion of patients in whom a single causative drug was identified was reduced.…”

“…Toxic epidermal necrolysis (TEN) and Stevens–Johnson syndrome (SJS) are severe, life‐threatening, mucocutaneous reactions with high mortality and are currently considered to represent different levels of severity of the same disease. Although most cases of TEN/SJS are thought to be caused by drug reactions, they may also be related to Mycoplasma pneumoniae infection and herpes simplex virus . Both TEN and SJS may cause damage to multiple organ systems and may cause skin pain (erythema, blisters, extensive epidermal exfoliation), eye, mouth and genital mucosa reactions, and multiple organ dysfunction.…”

“…Although most cases of TEN/SJS are thought to be caused by drug reactions, they may also be related to Mycoplasma pneumoniae infection and herpes simplex virus. [1][2][3][4] Both TEN and SJS may cause damage to multiple organ systems and may cause skin pain (erythema, blisters, extensive epidermal exfoliation), eye, mouth and genital mucosa reactions, and multiple organ dysfunction. Cases are classified as TEN or SJS according to the degree of epidermal sloughing.…”