key: cord-0958880-f0gorvnx
authors: Jin, Haoxing D.; Siatkowski, R. Michael; Siatkowski, Rhea L.
title: Ocular manifestations of mycoplasma-induced rash and mucositis
date: 2020-07-02
journal: J AAPOS
DOI: 10.1016/j.jaapos.2020.04.006
sha: 4d48aa97b64b4a162e9a837b53be9d93b295ad27
doc_id: 958880
cord_uid: f0gorvnx

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was no membranous formation. There were short fluorescein-staining strands of mucus adherent to the anterior surface of the cornea and conjunctiva bilaterally. The remainder of the anterior segment evaluation as well as dilated fundus examination were within normal limits. Physical examination was positive for bilateral diffuse wheezing and two erythematous, subcentimeter targetoid lesions on the right radial palm. A chest radiograph showed bilateral upper lobe alveolar opacity consistent with multifocal infectious process without effusion or pneumothorax.

The initial infectious workup was negative for blood culture, group A Streptococcus rapid antigen screen, and nasopharyngeal swab PCR testing for adenovirus, coronavirus, human metapneumovirus, rhinovirus, influenza A, influenza B, parainfluenza, respiratory syncytial virus, Bordetella pertussis, Chlamydophila pneumonia, and Mycoplasma pneumoniae. A presumed diagnosis of bilateral viral hemorrhagic conjunctivitis was made, and the patient was started on preservative-free artificial tears and erythromycin ointment. Pseudomembranes were found in the inferior fornices bilaterally and were carefully peeled.

Conjunctival swab testing for HSV PCR and coxsackieviruses cultures were sent at this point and were negative. Topical prednisolone acetate 1% four times daily and moxifloxacin 0.5% four times daily were added to the existing treatment regimen. A ProKera (Bio-Tissue, Miami, FL) amniotic membrane was placed over the left eye for 6 days to help with comfort and to aid corneal reepithelization. A repeat infectious workup revealed elevated Mycoplasma pneumoniae IgG (1893 U/mL; negative range, <100 U/mL) and IgM (5662 U/mL; negative range, <770 U/mL) serum titers.

The patient reported significant improvement in her ocular symptoms after the amniotic membrane placement. On day 10 of hospitalization, her visual acuity improved to 20/25 in the right eye and 20/30 in the left eye, and corneal epithelial defects had completely resolved without filamentous deposits. The patient was discharged from the hospital on day 13. Two months after the initial hospitalization, the subconjunctival hemorrhage and oral ulceration had completely resolved, and the visual acuity returned to her previous baseline.

Mycoplasma pneumoniae is a common cause of upper respiratory infection in children. Up to 94% of the Mycoplasma-associated infections may produce extrapulmonary manifestations, which most commonly involve the mucous membranes (94% oral, 82% ocular, and 63% urogenital mucositis). 1 MIRM and SJS/TEN can have similar clinical presentations, namely, mucocutaneous eruptions involving the ocular, oral, and genitourinary mucosal surfaces. However, MIRM differs from SJS/TEN in that the former is more commonly seen in children (mean age, 11.9; male, 66%) and is associated with mucositis alone or prominent mucositis with minimal cutaneous involvement. 2, 3 When the skin is involved, the rash in MIRM is typically sparse and is characterized by vesiculobullous or targetoid cutaneous lesions. By contrast, SJS/TEN often presents in adults (mean age, 47.1; female, 66%), with large, widespread, purpuric, coalescing bullous lesions that progress to sloughing and necrosis. [2] [3] [4] Initially, our patient's Mycoplasma antibody testing was negative. This could be secondary to the temporal profile of disease process, because Mycoplasma IgM is typically produced within 1 week of initial infection and peaks at 3-6 weeks. 5 The patient's otherwise negative infectious workup, along with the atypical oculomucocutanous findings, warranted a repeat infectious laboratory at 1 week into hospitalization, which yielded highly positive Mycoplasma pneumoniae IgG and IgM titers.

Of the reported cases of MIRM in the literature, 5-10 the mean age of presentation was 21.4 years (range, , and all cases had conjunctival involvement without corneal involvement except for a patient reported by Santos and colleagues, who treated their patient with ocular occlusion, topical oxytetracycline ointment, and intravenous immunoglobulins at a dosage of 1 g/kg/day for 3 days, with a rapid improvement. 8 None of the reported cases required amniotic membrane transplant, and all recovered without ocular sequelae except for 1 case with eyelid margin scar affecting the meibomian glands. 9 There have been no established treatment guidelines for ocular involvement of MIRM; however, aggressive lubrication combined with topical steroids and antibiotics often leads to a complete recovery. In cases that are more severe, amniotic membrane transplantation can afford symptomatic pain relief and aid in visual recovery.

Pediatricians and ophthalmologists should be familiar with this disease entity and consider amniotic membrane transplantation as an additional treatment option when the patient's clinical course worsens while on topical therapy.

The clinical presentation of pediatric mycoplasma pneumoniae infections-A single center cohort

Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review

Comprehensive survival analysis of a cohort of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis

Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme

Mycoplasma pneumoniae-associated mucositis-case report and systematic review of literature

Bilateral limbus-sparing conjunctivitis in a boy with rash and pneumonia

Mycoplasma pneumoniae-associated mucositis with cutaneous involvement-a case report

Mycoplasma pneumoniae-induced rash and mucositis: a recently described entity

Ophthalmic manifestations of mycoplasma-induced rash and mucositis

Mycoplasma pneumoniaeassociated mucositis: a recently described entity

Legends FIG 1. External photographs showing bilateral conjunctival injection (A) and oral ulceration (B) during initial hospitalization