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 manifestation.
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 The patients’ parents understand that name and initials will not be published.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.
A 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 hospital.
Physical 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.
Initial 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.
The 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.