A Case of Mycoplasma pneumoniae-Associated Mucositis
James J. Contestable, MD, and Matthew L. Ward
Contestable JJ, Ward ML. A case of Mycoplasma pneumoniae-associated mucositis. Consultant. 2017;57(12):698-699.
A 19-year-old man presented to the clinic onboard an embarked US Navy aircraft carrier with concern for 7 days of fever, myalgias, sore throat, and nonproductive cough. At that visit, he had received a diagnosis of an upper respiratory tract infection and had been provided with pseudoephedrine, guaifenesin, and ibuprofen for symptomatic treatment.
He presented again 24 hours later with new-onset erosions of the buccal mucosa and received a diagnosis of a viral syndrome and possible herpes simplex virus (HSV) infection. He was asked to continue taking ibuprofen for pain and was given valacyclovir for presumed herpes stomatitis.
The next day, the patient presented again, this time with extensive erosions throughout his buccal mucosa that were sharply demarcated to the keratinized skin of the vermilion border (Figure 1). He reported malaise, an intermittently productive cough, and slightly blurred vision. He had fever (temperature as high as 39.0°C), notably malodorous breath, and moderate conjunctival injection (Figure 2). He had no cutaneous findings and no genital or anal mucosal lesions. His visual acuity was slightly decreased from a baseline of 20/20 bilaterally to 20/30 OD and 20/25 OS. His lungs were clear to auscultation in all fields, and chest radiography findings were normal. Results of a complete blood cell count (CBC) showed only mild leukocytosis (11,200 white blood cells/µL) without a left shift.
Figure 1: Extensive buccal mucosa erosion occurred abruptly after the prodromal phase, sparing the keratinized skin of the outer lip.
Figure 2: Conjunctival injection with noted conjunctival defects during slit lamp examination. Fluorescein staining was not noted in the corneas but was otherwise noted across the entire conjunctivas. The yellow-orange substance at the medial canthus is fluorescein.
He was admitted to the ward onboard the ship and was continued on valacyclovir. He was kept on a liquid diet as tolerated, was started on maintenance intravenous fluids and opioid pain medications, and was provided with viscous lidocaine swish-and-spit solution.
Slit lamp examination revealed extensive uptake of fluorescein over the nasal and temporal bulbar conjunctivas, with less involvement of the superior and inferior bulbar conjunctivas. The corneas were mostly spared, with findings notable only for superficial punctate keratitis.
The differential diagnoses considered at that time included erythema multiforme major, HSV or other viral mucositis, and Stevens-Johnson syndrome (SJS). Oral azithromycin and topical erythromycin ophthalmic ointment were added to his regimen. Oral and ophthalmic corticosteroids were considered at that time but were not started. He received daily slit lamp examinations to screen for signs of HSV keratitis, but no changes to the cornea or ulcerations were noted. His visual acuity normalized on day 3 of his inpatient stay. He slowly improved, began taking in solid foods, and was discharged after 5 days as an inpatient.
Three weeks after his initial presentation, the ship pulled into port, and blood samples were drawn for HSV and Mycoplasma pneumoniae antibody testing. Results were negative for HSV immunoglobulin G (IgG) and immunoglobulin M (IgM), but the M pneumoniae IgG level was 810 U/mL (reference range, 0-99 U/mL) and the IgM level was 1154 U/mL (reference range, 0-769 U/mL). He recovered fully without sequelae after 4 weeks.
M pneumoniae infections typically are mild but can be associated with a mucositis similar to that seen with SJS. M pneumoniae-associated mucositis (MPAM) is a complication of mycoplasma infection that typically affects the oral, ocular, and genital mucosa.1 This presentation of mucositis has also been referred to as Fuchs syndrome, atypical SJS, incomplete SJS, or erythema multiforme major.1-3 A recent literature review suggested that as many as half of all patients with M pneumoniae infection have cutaneous manifestations.1
MPAM is more common in children, with one study suggesting an average age of occurrence of 11.9 years.1 Oral, ocular, and genital mucosal erosions are common and can occur alongside prodromal symptoms such as fever, cough, and sore throat.2-4
The diagnosis relies on symptomatology and serologic test results.1 IgG and IgM antibodies are commonly used to determine the presence of acute infection in a patient.1 However, it has been suggested that immunoglobulin A be utilized for determination of acute infections, since its level peaks earlier and declines faster than that of IgM.5
No consistent treatment recommendations exist for patients with MPAM, although macrolides are typically given in an effort to treat suspected M pneumoniae infection.1,2,4 Systemic corticosteroids are also used, but the efficacy of this treatment approach has not been established.1,4,5 One case report utilized intravenous immunoglobulin (IVIG) therapy for refractory mucositis.6
Ocular complications are the most commonly reported sequelae.1,6 We recommend treatment with erythromycin ointment or other lubricating antibiotics for signs of severe conjunctival mucositis and/or corneal dryness. We considered the use of ocular corticosteroids to help prevent inflammation-related complications such as symblepharon, since the use of topical corticosteroids reduces ocular sequelae in cases of SJS and toxic epidermal necrolysis.7 Further investigation is needed regarding efficacy of macrolides, systemic corticosteroids, IVIG, and ophthalmic topical corticosteroids in the treatment of MPAM.
This syndrome can masquerade as SJS, viral mucositis, or erythema multiforme major upon initial presentation. However, the treatment and prognosis differ for each of these conditions. SJS and HSV-related mucositis were part of our differential diagnosis in this patient’s case. The capability of the laboratory onboard an aircraft carrier is mostly limited to a CBC, a comprehensive metabolic panel, and urinalysis. Some basic microscopy and blood tests using point-of-care portable analyzers also are possible onboard. Medevac to a higher level of care is always a consideration when treating inpatients while at sea. If this patient’s syndrome had been more severe, or if he had begun to exhibit symptoms of SJS or ocular HSV infection, he would have needed specialty care that was unavailable onboard. Fortunately, his symptoms plateaued, and his visual acuity returned quickly. Signs of corneal involvement, SJS-like cutaneous symptoms, or a lack of clinical improvement would have prompted expedited medevac from the ship.
The diagnosis of MPAM requires a high index of suspicion, and the condition has a good prognosis.
James J. Contestable, MD, is a resident physician in dermatology at Naval Medical Center San Diego, California.
Matthew L. Ward is a prior-service corpsman in the US Navy and is a current student at the University of Texas at Austin.
DISCLAIMER: The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, the Department of Defense, or the United States Government.
- Canavan TN, Mathes EF, Frieden I, Shinkai K. Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. J Am Acad Dermatol. 2015;72(2):239-245.
- Mangal S, Narang T, Saikia UN, Kumaran MS. Fuchs syndrome or erythema multiforme major, uncommon or underdiagnosed? Indian J Dermatol Venereol Leprol. 2015;81(4):403-405.
- Li K, Haber RM. Stevens-Johnson syndrome without skin lesions (Fuchs syndrome): a literature review of adult cases with Mycoplasma cause. Arch Dermatol. 2012;148(8):963-964.
- Trapp LW, Schrantz SJ, Joseph-Griffin MA, Hageman JR, Waskow SE. A 13-year-old boy with pharyngitis, oral ulcers, and dehydration. Pediatr Ann. 2013;42(4):148-150.
- Vujic I, Shroff A, Grzelka M, et al. Mycoplasma pneumoniae-associated mucositis—case report and systematic review of literature. J Eur Acad Dermatol Venereol. 2015;29(3):595-598.
- Varghese C, Sharain K, Skalski J, Ramar K. Mycoplasma pneumonia-associated mucositis. BMJ Case Rep. 2014. doi:10.1136/bcr-2014-203795
- Sotozono C, Ueta M, Koizumi N, et al. Diagnosis and treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis with ocular complications. Ophthalmology. 2009;116(4):685-690.