1- Pediatric Medical Staff Group, Universitas Indonesia Hospital, Faculty of Medicine, Universitas Indonesia, Depok, Indonesia.
2- General Practitioner Staff Group, Universitas Indonesia Hospital, Faculty of Medicine, Universitas Indonesia, Depok, Indonesia.
3- Dermatology and Venereology Medical Staff Group Universitas Indonesia Hospital, Faculty of Medicine, Universitas Indonesia, Depok, Indonesia.
4- Ophthalmology Medical Staff Group, Universitas Indonesia Hospital, Faculty of Medicine, Universitas Indonesia, Depok, Indonesia.
Background: Erythema multiforme (EM) is an
immune-mediated self-limited reaction that has mucocutaneous eruption
Aim: The aim of this case report is to acknowledging the
possibility of coinfection in EM to give the proper treatment.
Case Description: We report a unique case
of Mycoplasma pneumonia and Herpes Simplex Virus-2 positive in immunocompetent
patient with erythema multiforme. Coinfection of Mycoplasma pneumonia and
Herpes Simplex Virus (HSV) infection is rarely presenting in an immunocompetent
patient. The patient was admitted with a worsening blister and erosion on oral
and genital mucosa, along with rashes on the extremities and trunk. The patient
also had a fluctuating fever and productive cough. The skin examination showed
multiple erythematous papules and plaques with dusky area and blister in some
central plaques that resembled target lesion. The patient tested positive for
Mycoplasma pneumonia and Herpes Simplex Virus (HSV) IgM and IgG serology. The
patient received supportive therapy, levofloxacin, acyclovir,
methylprednisolone, and therapy for ocular, oral, and skin lesions. Systemic
symptoms and cutaneous lesion improved after hospitalization without sequelae.
Conclusion: Although it is rare, coinfection must be taken into consideration for the cause of EM.
Key words : Erythema multiforme, Mycoplasma pneumonia, herpes
simplex virus, mucocutanous eruption, Case-report
Erythema multiforme (EM) is an immune-mediated
self-limited reaction that has mucocutaneous eruption manifestation.
This is a case report and
the authors certify that they have obtained all appropriate patient consent
forms. The patient’s parents have given their consent for clinical information
to be reported in this study in the form. The patients’ parents understand that
name and initials will not be published. This case report already approved by
the hospital ethical policy.
7-year-old boy presented with a worsening blister and erosion on oral and
genital mucosa, along with rashes on the extremities and trunk 1 week before
admission. He also had a fluctuating fever and productive cough two weeks
before admission. He was treated with amoxicillin on 3rd day of the
symptom, and the fever diminished. However, a week before admission, the fever
and the productive cough recurred. Subsequently, he had blisters and erosion on
the lips, genital and perianal area. Redness appeared on both eyes with
productive mucous discharge and palpebral crust. The rash initially appeared as
erythematous papule and then developed into plaque with a dusky area and
blister in the centre of the plaque. The patient came to another clinic and was
given azithromycin, acetaminophen, and oral topical steroid and referred to our
examination revealed stomatitis with lip edema, erosion, brownish crust and
pus. There was conjunctivitis on both eyes with purulent discharge and later
pseudo-membrane on the conjunctiva tarsal. There were multiple papules and
plaques with dusky area and blister in the center of some plaque that resemble
target lesion on the lower and upper extremities, trunk, glans penis, and
perianal, Nikolsky sign was negative.
The patient was diagnosed with erythema multiforme major.
laboratory results showed leukocytosis (12.950/μL) and increased erythrocyte
sedimentation rate (20 mm/hour), C-reactive protein (43.4 mg/L) and positive
for Mycoplasma pneumonia IgM and IgG with ELISA method. We did not find any
immunocompromised evidence in the patient.
patient received supportive therapy along with topical treatment for the
ocular, oral, and skin lesions. The patient received gentamycin sulfate 0.3%
antibiotic eye-ointment for ocular lesion, as well as Prednisolone acetate eye
drop with routine pseudo-membrane removal by conjunctiva scrapping. We treated
him with empirical Levofloxacin and methylprednisolone.
Infection marker was improved after antibiotic administration, but patient had persistent fever (but lower temperature than previous measurement) with progressing lesion. Mucosa and skin lesions continued to extend with atypical target lesions accompanied by blistering. Leukocyte and CRP were improving even though he still had a persistent fever and progressing lesion. We further performed other workups for EM, such as HSV serology evaluation and started empirical intravenous Acyclovir. We tapered off the methylprednisolone dose within a week. In the following days, the result of the IgM HSV-2 antibody was positive. After acyclovir administration, the skin lesion and the fever were improved. PCR test for SARS-CoV2 was performed in sequential manner and showed negative result.