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Mycoplasma pneumoniae e A common cause of SJS/TEN Ashok Kapse* Consultant Pediatrician, Department of Pediatrics, Kapse Children Hospital, Surat 395001, Gujarat, India
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abstract
Article history:
Mycoplasma pneumonia have been associated with SteveneJohnson syndrome, erythema
Received 25 March 2013
multiforme and toxic epidermal necrolysis. Mycoplasma pneumoniae is the most common
Accepted 2 April 2013
infectious agent associated with SteveneJohnson syndrome. Among patients with
Available online xxx
M. pneumoniae infection, dermatological manifestations are one of the most common complications. Skin and mucosal manifestation seen during the course of SteveneJohnson
Keywords:
syndrome due to Mycoplasma infection is presented in this article. Copyright ª 2013, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights
SJS/TEN
reserved.
Mycoplasma pneumoniae Epidermonecrolysis Igm mycoplasma IVIG
A 5-year male child presented in emergency on 29-5-2012 with complaints of fever cough and rash for last five days (Fig. 1). History revealed that child developed fever on 24th May 2012; within few hours reddish bumps started erupting on trunks. An orthodox family considered it as “Maharaj” (GOD incarnation) and refrained from seeking any kind of medical help. Next few days rash quickly spread on allover the body and converted into fine blisters (Fig. 2) and at places skin got denuded (Fig. 3); simultaneously his lips became inflamed, cracked, and painful creating difficulty in oral feeding (Fig. 4); subsequently a blackish crust engulfed penile tip (Fig. 5) this frightened the family and compelled them to seek medical treatment. Anal site was unaffected (Fig. 6).
1.
Physical
On physical examination child was conscious and alert but appeared sick and miserable; his eyes were congested with mucopurulent discharge (Fig. 7); lips were black, cracked and
there was excessive salivation; tongue was clear, oral mucosa and throat were red but devoid of any discharge or exudates; body was covered with small non-confluent and confluent blisters, at places skin was denuded; penile tip besides being black and crusted was discharging mucopurulent secretions. Except for crackles systemic examination was unremarkable.
2.
Investigations
Investigation results were as follows: Blood counts were: HB 11.4 g%, TWBC-10100, Band-3, N-50, L-23, M-3, E-21; CRP was 17 mg/L; urine showed 18e20 pus cell/HPF, 1e2 RBC, urine culture no growth; SGPT-130, S. creatinine 0.5 mg/L, Blood culture e no growth. HIV, HSV negative; IgM Mycoplasma pneumoniae positive (1.5 by EIA), [reference range negative below 0.8, borderline 0.8e1.1, positive 1.1 above]. Chest X-ray was normal. Child was put on amikacin, and azithromycin. Urgent dose of IVIG 1 g/kg BW was infused, a single dose of methyl
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[email protected]. 2212-8328/$ e see front matter Copyright ª 2013, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights reserved. http://dx.doi.org/10.1016/j.pid.2013.04.001
Please cite this article in press as: Kapse A, Mycoplasma pneumoniae e A common cause of SJS/TEN, Pediatric Infectious Disease (2013), http://dx.doi.org/10.1016/j.pid.2013.04.001
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Fig. 1 e Miserable looking child. Fig. 3 e Patches of denuded skin.
prednisolon (30 mg/kg BW) was given and eye and skin care was instituted in consultation with respective specialist. Oral feeds were resorted by a large sized straw as parents were unwilling for nasogastric tube.
3.
Course during hospitalization
Within few days child started recovering; became afebrile, cough decreased, his outlook improved, oral intake increased however his skin begin to peel off (Figs. 8e10), within a short period big part of epidermis got detached showing behind shiny red recovering dermis (Figs. 11 and 12). By end of week he made complete recovery and was discharged.
4.
Discussion
StevenseJohnson syndrome (SJS) & Toxic epidermal necrolysis (TEN) are severe adverse cutaneous reactions to drugs and certain microbes; reaction predominantly involves the skin and mucous membranes.1 Characteristically reaction has erythema, mucocutaneous tenderness and epidermal detachment which may present as blisters. Confluent blisters may culminate into sheet wise epidermal detachments leaving behind large portions of denuded skin.1
Fig. 2 e Fine blisters.
Currently, TEN and SJS are considered to be two ends of a spectrum of severe epidermolysis, differing only by their extent of skin detachment: epidermolysis involving less than 30% of body surface area is termed as SJS while epidermolysis beyond 30% is called as TEN.1,2 In majority of SJS/TEN cases drugs are incriminated as the main cause3; drugs at “high” risk of inducing TEN/SJS includes: sulfonamide-antibiotics, trimethoprimesulfamethoxazole, allopurinol, carbamazepine, quinolones, aminopenicillins, cephalosporins, phenytoin, phenobarbital and NSAID’s of the oxicam-type. Although drugs are commonly identified cause for SJS/TEN nevertheless certain microbial infections such as Herpes simplex virus and M. pneumoniae are well documented causes of this menacing disease. M. pneumoniae is now known to be a frequent respiratory pathogen in children as well as in adults. M. pneumoniae infects the upper and lower respiratory tracts, leading to upper respiratory tract infection, bronchiolitis, tracheobronchitis, bronchitis and community-acquired pneumonia.4,5 It is also associated with asthma exacerbations.6 Interestingly off late Mycoplasma is emerging as nonrespiratory pathogen4; Mycoplasma respiratory tract infections
Fig. 4 e Swollen and cracked lips.
Please cite this article in press as: Kapse A, Mycoplasma pneumoniae e A common cause of SJS/TEN, Pediatric Infectious Disease (2013), http://dx.doi.org/10.1016/j.pid.2013.04.001
p e d i a t r i c i n f e c t i o u s d i s e a s e x x x ( 2 0 1 3 ) 1 e5
Fig. 5 e Black crust around penile tip.
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Fig. 8 e Skin peeling.
been described in the literature. There is a well-known association between Mycoplasma and StevenseJohnson syndrome, erythema multiforme and toxic epidermal necrolysis. M. pneumoniae is the most common infectious agent associated with StevenseJohnson syndrome.7 A Japanese review of literature compared SJS/TEN induced by drug VS Mycoplasma. Review identified following characteristics for Mycoplasma associated SJS/TEN8: patients with M. pneumoniae-associated SJS were younger than those with drug-induced SJS/TEN; ocular involvement was more frequently observed in M. pneumoniae-associated SJS/TEN than in drug-induced SJS however sequelae was commoner in drug
Fig. 6 e Normal anal site.
are associated with inflictions of non-respiratory mucosas, central nervous system (CNS) and other tissues. 25% of individuals infected with M. pneumoniae may experience extra-pulmonary complications. These extra-pulmonary manifestations could occur before, after, during or in the absence of respiratory symptoms. Extra-pulmonary manifestations may occur not less than 3 days after the onset of respiratory disease and for 2e3 weeks after the respiratory disease has resolved. Among patients with M. pneumoniae infection, dermatological manifestations are one of the most common complications. A wide range of skin and mucosal manifestations has
Fig. 7 e Inflammed eyes with mucopurulent discharge.
Fig. 9 e Skin peeling in sheets lower limb.
Please cite this article in press as: Kapse A, Mycoplasma pneumoniae e A common cause of SJS/TEN, Pediatric Infectious Disease (2013), http://dx.doi.org/10.1016/j.pid.2013.04.001
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p e d i a t r i c i n f e c t i o u s d i s e a s e x x x ( 2 0 1 3 ) 1 e5
Fig. 12 e Shining dermis lower limb recovery period.
Fig. 10 e Skin peeling in sheets lower limb.
induced; respiratory disorders were observed more frequently in M. pneumoniae-associated SJS/TEN; internal organ involvement: hepatitis, renal dysfunction, encephalopathy and gastro-intestinal symptoms less frequent than drugs induced and over all better prognosis for Mycoplasma associated SJS/ TEN. The exact pathomechanism of skin and mucosal disease is unknown, but immune complex-mediated vascular injury, cell-mediated immune response and cytotoxic injury to epithelial cells, and autoimmune mechanisms have all been suggested.9
Some cases of StevenseJohnson syndrome were reported to exclusively affect mucosal membranes, leaving the skin intact, these cases are labelled differently as atypical SJS, or Mycoplasma-associated mucositis.10 Presently it is unclear whether this entity is a SJS variant or a new entity. Patients with oral, as well as genitourinary, mucosal lesions, generally manifest with fever and generalized fatigue. Antimicrobial therapy rapidly resolves the clinical condition. Use of non-allopathic medicines is not uncommon in our circumstances and a high eosinophilic count in presented case rose some doubts about such occurrence however parent’s total denial forced us to contemplate and explore microbial involvement. Mycoplasma diagnosis rests on demonstration of cold agglutinins, culture, serology, and PCR.4 Cold agglutinins are irrelevant for diagnosis as they lack of sensitivity and specificity; many bacteria and viruses could also produce cold agglutinins. While culture is undoubtedly a gold standard it is expensive, time-consuming, and is available only in reference laboratories. Therefore serological tests for anti-Mycoplasma antibody are the commonest method for Mycoplasma diagnosis. Among the various serological tests such as ELISA, passive agglutination, and complement fixation ELISA is the most sensitive. A combination of ELISA & PCR is believed to be the best. In our case detection of IgM antibodies by ELISA clinched the diagnosis and institution of azithromycin a new generation macrolide lead to a swift and complete recovery.
Conflicts of interest The author has none to declare.
references
Fig. 11 e Shining dermis upper limb recovery period.
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Please cite this article in press as: Kapse A, Mycoplasma pneumoniae e A common cause of SJS/TEN, Pediatric Infectious Disease (2013), http://dx.doi.org/10.1016/j.pid.2013.04.001
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Please cite this article in press as: Kapse A, Mycoplasma pneumoniae e A common cause of SJS/TEN, Pediatric Infectious Disease (2013), http://dx.doi.org/10.1016/j.pid.2013.04.001
