INTRODUCTION

Erythema multiforme (EM) is an immune-mediated self-limited reaction that has mucocutaneous eruption manifestation. ¹ EM has several etiologies; one infection is caused explicitly by Herpes Simplex Virus-1 (HSV-1). Other infectious on agents often causing EM are hepatitis B and C, Mycoplasma pneumonia, and parvovirus B19.² Cutaneous lesion characteristics of EM are target lesions with the diameter <3 cm, circular-shape, well-defined border, and consisting of 3 different zones; 2 concentric rings with different colours around the circular zone usually with dusky appearance, indicating epidermal damage forming bullae or crust. The presence of EM manifestation does not increase patient mortality rate, although increasing patient’s morbidity. Erythema multiforme generally occurs in young adults; nevertheless, it can occur in children. ^1,3   Finding the exact etiology of EM in a patient can secure early prompt treatment and would make a better prognosis for the patient and less hospitalization duration with more cost-effective treatment. There is still a small number of publications reporting double infection of Mycoplasma pneumonia and HSV infection. In fact, this case report is the first in Asia.

METHODOLOGY

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 The patients’ parents understand that name and initials will not be published.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.

CASE REPORT

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 3^rd 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.